Independent Contractor (Individual) Pre-Hire Information Form

Instructions: Complete Parts I through V of this form prior to contracting, or renewing, a contract for independent contractor (individual) services. All sections of this form are to be completed before submitting this document along with a Marketplace Requisition. Failure to complete the following sections truthfully may result in statutory violations (e.g. Internal Revenue Service Code or California Public Contract Code) and result in individual and/or departmental financial, or criminal, penalties. This form is to be completed by the unit or department submitting the Marketplace Requisition.

Part I: Requesting Department Information Marketplace Requisition No: Date: Department: Department Contact: Telephone: Cell: Email: UCSD Project Manager: Telephone: Cell: Email:

Part II: Proposed Contractor Information Proposed Contractor Name: Telephone: Cell: Email: Has the contractor been hired previously as a contractor? Yes No Address: If yes, provide contract or purchase order number(s): Contractor's Social Security number (SSN) and/or Federal Employer ID Number (FEIN) should be provided on W-9 form only. For more on W-9 collection, visit our Supplier Information form section for more information. If using SSN, is the If using SSN and individual is not a US Yes No Visa Type: individual a US Citizen? Citizen, provide Country of Citizenship:

Proposed Work Information Describe in full detail the services requested. Include deliverables, milestones, and special terms (include additional sheets if necessary):

Describe how and by whom the proposed contractor was selected including an extenuating circumstances:

N Will work be performed on campus? Yes Period of Performance Start Date: End Date: o N Will University equipment or supplies be used? Yes Rate of Pay: Total Not to Exceed Dollar Amount: o

Part III: Conflict of Interest Is the proposed contractor a current, or previous (within the last two years), UC employee? Yes No If yes, requesting department must also attach an “Employee-Vendor Relationship Disclosure (EVRD)” form with the requisition and is advised to consult with their Human Resources Talent Acquisition Specialist to make this determination. See UC Policy PPSM-82: Conflict of Interest for more information. If previously employed for UC, provide position: Department: Is it expected that the University will hire this contractor as an employee upon conclusion of proposed service? Yes No

Part IV: Internal Revenue Service Classification Factors Checklist Answer the following questions by selecting either “yes” or “no” in the columns below – one response per row. More information regarding the IRS classification factors is available on our website. Explanation for any answer may be submitted on a separate sheet. IRS Classification Factor Table Employee Contractor A. Behavior Control: Right to direct and control details and means by which contractor performs services. Will the department give the individual instructions as to when, where, and how he or she is Instruction Yes No to perform the job? Training Will the worker receive training from the University? Yes No

UC San Diego Procurement and Contracts – Revised 10/26/2017 PL Independent Contractor (Individual) Pre-Hire Information Form

IRS Classification Factor Table Employee Contractor B. Financial Control: Right to direct and control economic aspects of the worker’s activities. Has the worker invested in facilities such as office or equipment to perform the proposed Significant Investment No Yes services to commercial clientele? Payment of expenses Will the University pay the worker’s business or travel expenses in addition to the rate or fee? Yes No Services Available Does the worker make his or her services available to other businesses? No Yes Incremental Payment Will the University pay the worker by the hour, week, or month rather than by the job? Yes No Risk of Profit/Loss Will the worker bear the risk of making a profit or losing money under this arrangement? No Yes C. Relationship of Parties: Intent of parties concerning status and control of worker. Regular University Is the work to be performed part of the regular business of the University; teaching, research Yes No Business Activity and public service? Will a written agreement be executed between the University and the individual describing Agreement Document No Yes the individual as an independent contractor? Will the individual receive any UC employee benefits? Yes No Will the individual hire and supervise other persons on behalf of the University? Yes No Individual Status Is it a condition of the agreement that the individual personally provide service to the Yes No University? Can the individual terminate his or her relationship at any time without incurring any personal Yes No liability? Will the individual be submitting regular oral and/or written reports to the University, other Yes No Control of Individual than status updates? Will a University employee provide ongoing supervision to the individual? Yes No Will the individual have to follow University scheduled hours of work? Yes No

Part V: UC San Diego Department Authorization and Certification The responsible department authority is to complete this section. By authorizing this transaction, the department authority warrants and represents that the information provided is true and correct and is therefore approved by: Date: UC San Diego Department Phone: Authorized Signature: Cell: Printed Name: Email: Title or Position:

Part VI: UC San Diego Human Resources Authorization and Certification The responsible central human resources authority is to complete this section. By authorizing this transaction, the human resources authority warrants this relationship to be that of a contractor. Date: UC San Diego Human Resources Authorized Signature: Determination Comments: Printed Name: Title or Position:

Part VII: Procurement Determination

This section is to be completed by UC San Diego Procurement and Contracts. Determination by Procurement Manager or Designee:

Date: Authorized Signature:

Determination Comments: Printed Name: Title or Position:

UC San Diego Procurement and Contracts – Revised 10/26/2017 PL Independent Contractor (Individual) Pre-Hire Information Form

UC San Diego Procurement and Contracts – Revised 10/26/2017 PL