ࡱ> qp f2ɀ\p Windows User Ba==<[;28X@"15Arial15Arial15Arial15Arial15Arial165Rockwell Extra Bold15Arial15Arial15Arial15Arial1 5Arial1 5Arial1 5Arial15Tahoma15Arial1 5Arial1$5Arial15Arial15Arial15Arial1zArial1 zArial1zArial14zArial1 zArial1zArial1zArial1,8zArial18zArial18zArial1>141<zArial1?zArial1h8zCambria1zArial1 zArial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)"Yes";"Yes";"No""True";"True";"False""On";"On";"Off"],[$ -2]\ #,##0.00_);[Red]\([$ -2]\ #,##0.00\)                                                                      ff + ) , *      P  P         ` !      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Currency [0]/Explanatory TextB5Explanatory Text 0 : Followed Hyperlink 1Good6Good  a2 Heading 1B Heading 1 I}O3 Heading 2B Heading 2 I}?4 Heading 3B Heading 3 I}235 Heading 44 Heading 4 I}6( Hyperlink 7InputpInput ̙ ??v 8 Linked CellF Linked Cell } 9Neutral<Neutral  e"Normal :Noteb Note   ;OutputrOutput  ???????????? ???<$Percent =Title1Title I}% >TotalHTotal OO? Warning Text: Warning Text XTableStyleMedium9PivotStyleLight16Mw_hKtE&X dsunbird1 - Personal View` aPICCfVf@ @bZ  /K3 A@@  ]R-DUKE UNIVERSITY/DUKE UNIVERSITY HEALTH SYSTEMPhone:Company name or DBA:Part A Date:No Independent Contractor ChecklistYesIndependent Contractor StatusZWill the individual decide how work is to be done without ɫֱ's direction or instruction?Employee Status1Is the individual engaged for a specific project?A continuing relationship is not anticipated. Projects will be awarded only when the need arises, and will be based on bids and specifications.+ɫֱ anticipates a continuing relationship./Can the individual set their own hours of work?Responsible for own schedule.ɫֱ sets the hours.$Works for only one client at a time..Does the individual perform services off-site?6Does individual furnish their own tools and materials?>Individual furnishes tools, equipment, materials and supplies.'No advertising of services or business.Based on the above checklist and my knowledge of the proposed contract, it is my determination that the individual providing the services should be classified as an:Name: Department:Title:Control Analysis Cost Object:Individual Name:7Choose one answer for each question - either Yes or No.AService Provider Information - Fill in all applicable information$Employee (Contact Corporate Payroll)I have reviewed the above responses and acknowledge that as a person with authority over the indicated cost object, I understand that should the Internal Revenue Service ("IRS") disagree with this classification ɫֱ University may hold my department financially responsible for any additional compensation (due to gross up, including fringe rate), taxes, interest, or penalties that the IRS or other regulatory bodies might assess.Signature of reviewerOIs this an honorarium for a speech/presentation in accordance with GAP 200.130?Part DStop and pay as employee1Does the service provider work for other clients?`Can be performed by individual's subcontractors or employees. The individual has other employeesMMust be performed by individual. The individual does not have other employees=Currently performs services for multiple unrelated customers.JDoes the individual recognize profit and loss based on business decisions?~Individual bears risk of economic gain or loss as a result of the individual's services. (e.g. set deliverable at a set price)Tɫֱ compensates regardless of performance or outcome. (e.g. hourly or monthly rate)MDoes the individual advertise their services or actively recruit new clients?x ** Current employees -- STOP -- Do not use this form. All current employees must be paid through Corporate Payroll.** ! 7Complete IRS form W-9 and skip to certification sectionControl Factors Part B ESERFContinue to Part CPart COIs the individual responsible for their own training? (if training is required)/ɫֱ will provide training for this assignment.[ɫֱ provides facilities and equipment, furnishes tools, equipment, materials and supplies.OIndividual determines specific detailed tasks required for the work or project.NResponsible for own training related to this assignment. (Specific engagement)hIf company is a Corporation, LLC or partnership with an EIN STOP this form does not need to be completed=Can the individual hire their own employees for this project? How will the individual be paid?Signature of service providerWill the individual be performing services in substantially similar capacity or under the similar direction and control as when they were an employee? (same department/same supervisor)mMaintains own infrastructure such as office space, email and server and responsible for own business expensesɫֱ will add individual into daily operations with access to ɫֱ email, software (e.g. SAP), or required attendance at meetings. (Process through Payroll)!Part E Departmental Certification5Part F Service Provider Attestation and CertificationEmail:Under penalties of perjury, I certify that the above information is complete and accurate. If ɫֱ engages me as an independent contractor, I am [responsible for taxes, insurance coverage, and business expenses, and that I am not eligible for any employer-provided benefits.tI understand that if I accept employment in the future I must immediately notify the office of Procurement Services.<ɫֱ determines specific detailed tasks for work or project.Zɫֱ pays on an hourly, or monthly basis. (Individuals invoice will bill by hour or month)pɫֱ will pay invoice on a per project basis. (Individuals invoice does not reference an hourly or monthly rate)!Independent Contractor (more Yes)=Conclusion (more Yes than No indicates Independent Contrator)Former Employee (Individuals)I certify that I have first hand knowledge of the relationship in order to prepare or review the above questionnaire with complete and thoughtful accuracy.| Is this individual performing substantially similar services under similar direction and control as other ɫֱ employees? If yes, pay as employee.;Continue to question 2 and Provide former job title below:IAdvertises business in: Publications Yellow pages Website:URL:Z; ;~=rA?52@&ZCNE G NJBLVOJccB f2ɀ >p5Ӈ  dMbP?_*+%&?'p= ף?((\?)(\?M\\FS-PRN-SRV01\Support02- HP LC odXXLetterDINU" Ńɮ@SMTJHP LaserJet M3035 MFP PCL 5InputBinFORMSOURCERESDLLUniresDLLHPDocUISUITrueResolution300dpiDuplexVERTICALESPRITSupportedTruePaperSizeLETTEREdgeToEdgeFalseOrientationPORTRAITHPPaperSizeDuplexConstraintsSTATEMENTHPDocPropResourceDatahpchl6de.cabPrintQualityGroupPQGroup_2HPSmartDuplexSinglePageJobTrueHPSmartDuplexOddPageJobTrueHalftoneHPDitherMatrixTextAsBlackFalseHPXMLFileUsedhpc30355.xmlHPOrientRotate180FalseMediaTypeAUTOOutputBinAutoEconomodeFalseCollateONHPPaperSizeALMConstraintsENV_10AlternateLetterHeadFalseTTAsBitmapsSettingTTModeOutlineGraphicsModeRASTERMODERETChoiceTrueHPColorModeMONOCHROME_MODEHPPDLTypePDL_PCL5HPMaxResolutionPDM_600DPIHPPJLEncodingUTF8HPJobAccountingHPJOBACCT_JOBACNTHPBornOnDateHPBODJRConstraintsJRCHDPartialJRHDInstalledJRHDOffJRHDNotInstalledJRHDOffHPJobByJobOverrideJBJOHPDuplicateJobNameOverrideSWFWHPEnableRAWSpoolingTrueHPConsumerCustomPaperTrueHPManualDuplexDialogItemsInstructionID_01_FACEDOWN-NOROTATEHPManualFeedOrientationFACEDOWNHPOutputBinOrientationFACEUPHPManualDuplexDialogModelModelessHPManualDuplexPageOrderEvenPagesFirstHPMapManualFeedToTray1FalseHPPrintOnBothSidesManuallyFalseHPManualDuplexPageRotateDriverRotateHPStraightPaperPathFalseHPNUseDiffFirstPageChoiceTRUEHPPageExceptionsFilehpcPE6deHPPageExceptionsInterfaceShowPageExceptionsHPPageExceptionsCoverInsertionPSAlignmentFilehpcLS6dePSServicesOptionPrnStat_SID_242_BID_270_HID_15521PSServices_DeviceandSuppliesStatusTRUEHPJobAccWoPinTrueHPSmartHubInet_SID_263_BID_276_HID_265HPSmartHub_OnlinediagnostictoolsTRUEHPSmartHub_SupportandtroubleshootingTRUEHPSmartHub_ProductmanualsTRUEHPSmartHub_CheckfordriverupdatesTRUEHPSmartHub_OrdersuppliesTRUEHPSmartHub_ShowmehowTRUEIUPHxAkAZԛ( ZP(1;kZhz(f+mJRAįEGxRzf/dvmj&﷼yf6 3hw ʒUWȠƻbk&g2<,D k_fIphP<߁2MyjR.$nb^cMDhJumtMn *wakXLNow ac Ŋh@ @0@0@0@@  @ Y@ Y@ Y@@@f@ @@@@ @@f@ @@  , ,.```````````````aaaaa -,.^___________________ D E*FFFFFFFFFFFFFFFFFFA &B BBA VUTZ@GA ~8 WXYCG A $  FFF A FFFFFFFFV  TUTUT FFF M      N(  k0 kK j l jHHj l jHjjjjjjjjj~ ? <  $  O .~ K@ J" RcR .RcR  1  [2 \*]]]]]]]]]]]]]]]]]] , k/ HH HH  H I H  H  HHHHHHHHH~ O? 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