Independent Contractor Form printable pdf download

Independent Contractor Form

Name ________________________________________

SSN ______________________

1. Is the worker given training by the State Agency?

_____ YES

_____ NO

1.a. If “YES”, please describe.

2. Is the worker given instruction the way the work is to be done?

_____ YES

_____ NO

3. Does the State Agency have the right to change the methods used

_____ YES

_____ NO

by worker or direct that person on how to do the work?

4. Is the worker required to follow a routine or a schedule established by the State Agency?

_____ YES

_____ NO

5. How often does the worker report to the State Agency?

5.a. What method is used by the worker to report to the State Agency?

5.b. For what reasons does the worker report to the State Agency?

6. How does the worker report his/her time to the State Agency?

7. What kind of tools/equipment/materials/supplies are provided by:

THE STATE AGENCY:

THE WORKER:

8. What kind of expenses are incurred by the worker in the performance of services

for the State Agency?

8.a. Is the worker reimbursed by the State Agency for any of these expenses?

_____ YES

_____ NO

If “YES”, please explain:

9. Will the worker perform the service personally?

_____ YES

_____ NO

Independent Contractor Form