Independent Contractor Determination Worksheet Template
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1Independent Contractor Determination Worksheet
Business Name:
Phone Number:
email
Please indicate School or Department that is contracting with you:
Indicators of Independent Contractor Status
Yes
No
Go to #2 Go to #3
Are you employed by another PERS employer OR have you been an employee of the Woodburn School District within the last 18
1
months (i.e.paid any money by our payroll department)?
Are you doing the same work for this project that you did when employed by the Woodburn School District?
2
Go to #4
Go to #3
Do you meet the legal definition of an Independent Contractor (ORS 670.600) as evidenced by the ability to certify to a majority of
3
Go to #4
Go to #5
the statements below?
Read the statements below: Check Yes or No as to each applies to you. There is no established set point as to whether the
number of yes’s or no’s constitutes an Independent Contractor or Employee – The District will make the final decision
3a
Provider, in the provision of the services:
Yes
No
Is free from direction and control over the means and manner of providing the services
Is customarily engaged in an independently established business
Is licensed under ORS Chapter 671 or 701 as required, and/or is responsible for obtaining any licenses or certificates
Pays his/her own business travel expenses
Provider, in the independence of the service work shall:
3b
Maintain a separate business location from the District, which could be a home office
Bear the risk of business loss in providing the services, as shown by factors such as: a) enters into fixed-price contract;
b) required to correct defective work; c) provides warranty and/or insurances such as indemnification, liability,
performance bonds or errors and omissions insurance
Determine how the desired results will be achieved
Provide services or does similar work for other Agencies/public within a 12 month period, or routinely engages in business
advertising, solicitation or other marketing efforts reasonably calculated to obtain new contracts to provide similar services
Retain significant control over the means and methods of performing work, including hiring and firing its employees
3c
Provider has a substantial investment in his/her chosen trade or business such as:
Furnish his/her own tools
Independently maintain business registrations, professional or occupational licenses (or both)
File Federal and State income tax returns in the name of his/her business
4. The Provider must be hired as a temporary employee. The District Human Resources Department will contact the Provider.
5.
Pursuant to District Board policy GCDA/GDDA, Individuals contracting with the district and their employees
who have direct unsupervised contact with students, shall also be required to submit to a nationwide criminal records
check and fingerprinting
.
Legal Name:
Yes, I will have unsupervised contact with students
Attach a list of all company employees and birth dates who will have direct, unsupervised contact with students
No, I will not have unsupervised contact with students
Date:
Business Office Use Only
Approved by:
Yes
No
The Contractor must be hired as an employee.
The Contractor may be hired as an independent contractor and paid through the AP Department
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