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Currency [0]/Explanatory TextG5Explanatory Text %0 : Followed Hyperlink 1Good;Good  a%2 Heading 1G Heading 1 I}%O3 Heading 2G Heading 2 I}%?4 Heading 3G Heading 3 I}%235 Heading 49 Heading 4 I}%6( Hyperlink 7InputuInput ̙ ??v% 8 Linked CellK Linked Cell }% 9NeutralANeutral  e%"Normal :Noteb Note   ;OutputwOutput  ???%????????? ???<$Percent =Title1Title I}% >TotalMTotal %OO? Warning Text? Warning Text %XTableStyleMedium9PivotStyleLight16`RSheet1Sheet2 Sheet3a|hlN U.S. CitizenLawful Permanent ResidentNonresident AlienYesNo InstructionsI. General InformationIII. Behavior ControlB3. Will the university provide personnel to help perform the work?K2. Will the individual receive a payment at regular payroll-like intervals?5Employee-Independent Contractor Checklist (continued)IC @5. Will the individual realize a profit (or loss) from the work?83. Is the duration of the position more than six months?I3. Will the individual set the curriculum and select the class materials?N3. Is the payment to the individual based on an hourly, daily or weekly basis?I4. Will the individual receive a flat fee or payment on a periodic basis?P2. Does the individual receive vacation or sick leave or other similar benefits?N2. Will the individual affect the grade or certification the student receives?'5. Is the course a degree prerequisite?If No, Check ICIf Yes, check ICIf No, check ICIn No, check IC$____________________________________Date!_________________________________ SignatureContact Phone X________________________________________________________________________________________Determination:Hire as employeeB__________________________________________________________________ Contact phone___________________________________________________________If no, check ICIndividual's nameU_____________________________________________________________________________________ Department`________________________________________________________________________________________________R4. Will the university provide the facility to the individual to perform the work?P2. Will the individual be required to follow the schedule set by the university?K1. Will the university reimburse the individual for out-of-pocket expenses?#V. Relationship between the PartiesHire as Independent Contractor64. Is the course offered by the university for credit?'If yes, consult with legal as to status2. Will the university expect to hire the individual as an employee immediately following termination of independent contractor status?3. At any time during the 12 months prior to the individual's independent contractor services, did the individual have an official university appointment or position and provide the same or similar services?h4. Does/did the university pay others who perform essentially the same or similar services as employees?1. Will a current university employee instruct the individual on how to do the work, rather than rely on the individual's expertise?t2. Will the university supply the individual with the necessary tools, materials, and equipment to perform the work?1. Will the university provide training (periodic or on-going) to the individual on the procedures to follow to perform the work?f6. Does the university have the right to withhold payment if it determines the work is unsatisfactory?W7. Can the university or the worker terminate at any point without incurring liability?Z4. Is the work performed by the individual part of the regular business of the university?1. Is the individual a guest lecturer who will conduct only a few sessions of a class and is not otherwise working at the university in a different capacity?6. Does the individual teach or present similar courses at other colleges, universities, or educational institutions or to the general public as part of a trade or business?Y1.Will the individual perform research for the university under a grant or other funding?2. Will the individual perform research for a university professor or employee who determines how the work is performed and the work schedule?p3. Will the individual collaborate with a university professor or employee or serve as an advisor or consultant?b1. Has the individual worked as an employee of 鶹 Pembroke at any time during the last 12 months?1. Is there a written agreement between the individual and the university describing the scope of the project and identifying the individual as an independent contractor?"Dept. Contact Name completing formTUniversity of North Carolina at Pembroke - Employee/Independent Contractor Checklist4Residency Status (Note: This is a Required Field)Director of Purchasing Approval Banner ID:-REQUIRED -Total Checks in IC Indicator ColumnCThe Internal Revenue Service requires the University to classify each worker as an employee or an independent contractor (IC) for purposes of income tax, Social Security, and Medicare withholding. Use the instruction to decide whether to check the IC (Independent Contractor) indicator box. No single factor determines an individual's status as an independent contractor. The Personal Services Contract and Checklist must be completed, agreement attached (if applicable), IC totaled, and sent to the Director of Purchasing for approval two (2) weeks prior to the event start date. If forms are received after the event date, will cause a delay in process and payment. Incomplete forms will be returned to the appropriate department. Note: Subject to be reviewed by Payroll, Human Services, and/or General Counsel, as needed. +A. Degree of Instruction Yes NO IC II. Relationship with the University Yes NO IC B. Training Yes NO IC IV. Financial Control Yes NO IC VI. Specific Classifications Yes NO IC B. Researcher Yes No ICNote: Attach to Personal Services Contract for Approved Independent Contractor or return forms to department if disapproved. 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