Independent Contractor Determination Request Form

IMPORTANT INFORMATION : All Independent Contractor (IC) determination requests must be reviewed prior to any work being done. The following questionnaire is to be completed by the department requestor and will be used to determine if the work can be conducted by an Independent Contractor.

Once completed, the determination may be subject to change based on any additional review or information received during the contract or employment processes.

Requestor Information

Department

Requested By (Full Name/Title)

Requestor Email

Requestor Extension

Worker Information

First Name

Last Name

Email Address

Multiple Requests

Bulk Requests: Please select the "Yes" option to add any additional workers performing the SAME scope of work. Please select the "No" option if this is for one worker request.

Yes, I have multiple workers to add.

No, I do not wish to add anyone else.

Phone Number

Phone

Date From

mm/dd/yyyy

Date Until

mm/dd/yyyy

Payment Amount Requested

Description of Services/Scope of Work

Please provide a detailed scope of work, outlining the proposed services and expected deliverables of this job. Include items such as event information, deliverables, information about the worker, etc. Additional information may be requested upon review:

Determination Questions:

Please verify ALL information is correct for the individual providing service before submitting responses. Thank you.

Question 1:

Is the proposed independent contractor a current CSU or state employee?

Yes

Question 2:

Has the proposed independent contractor retired or separated within the last two (2) years from the CSU system or a state institution?

Yes

Question 3:

Is the worker free from control and direction of CSUF in the performance of work?

Yes

Question 4:

Does the worker perform work that is outside the usual course of business for CSUF or the CSU system?

Yes

Question 5:

Is the worker customarily engaged in an independently established trade, occupation or business of the same nature as the work performed for CSUF?

Yes

Question 6:

Will the worker be required to comply with CSUF-provided instructions about when, where, and how to work?

Yes

Question 7:

Will the worker be provided with instructions/training by CSUF regarding the particular method or manner by which the work will be performed?

Yes

Question 8:

Is the work to be performed a regular part of CSUF business/work?

Yes

Question 9:

Will the worker be required to perform the work themselves?

Yes

Question 10:

Will the worker be hiring or supervising CSU employees?

Yes

Question 11:

Will the worker be able to hire and pay their own assistants?

Yes

Question 12:

Will the worker and CSUF have a continuing relationship?

Yes

Question 13:

Can the worker terminate their relationship without incurring a liability for failure to complete the job?

Yes

Question 14:

Does the worker offer similar services to others as part of their own business?

Yes

Question 15:

Will the worker be allowed to work concurrently for other organizations/clients while working for CSUF?

Yes

Question 16:

Will the worker be able to determine their own hours and priorities?

Yes

Question 17:

Will the worker be hired and paid to complete one specific job/project for CSUF?

Yes

Question 18:

Will the worker realize a profit or loss as a result of their services?

Yes

Question 19:

Will the worker provide their own tools or materials?

Yes

Question 20:

Will the worker be responsible for supervision of CSU-contracted employees?

Yes

Question 21:

Was the worker in a policy-making position or an MPP?

Yes

Question 22:

Will the worker participate in the process of planning, negotiations, transaction, or any part of the decision-making process?

Yes

Question 23:

Will the worker’s position be funded by a CSU contract?

Yes

Question 24:

Have you previously engaged this individual or entity for similar work?

Yes

Signature

I am submitting this request on behalf of the division.

By checking the box below, I hereby declare that the information provided in this document is true and correct and that I have sufficient knowledge of, authority, and responsibility for the work to be performed under this contract to effectively make this certification.

Date of Submission

mm/dd/yyyy

Send me a copy of my responses

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