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INDEPENDENT CONT Clear Form D RACTOR STATUS QUESTIONNAIRE WASHINGTON STATE Department of PO Box 48380 Olympia,WA 98504-8380 • www.drs.wa.gov Retirement Systems Toll Free: 1-800-547-6657 • Olympia Area: 360-664-7000 •TDD:360-586-5450 DRS provides this questionnaire as a tool to assist employers in determining if an individual is an independent contractor or an employee. The employer retains the questionaire. Section 1: Worker Data t k � Worker Name ✓ 0 CO 7 ID Number Date Evaluated , 3 Sa 'FS =i The burden of persuasin for claiming an individual as an independent contractor is on the individual or the employer making the claim. Refer to WAC 415-02-110 and the Internal Revenue Service for the rules governing independent contractor status. No one factor determines independent contractor status. You will need to review the relationship between the worker and the employer, and to evaluate whether the employer has direction or control over the means and methods of performing the worker's services. The terms of the contract and the actual arrangement under which the services are performed are also part of determining whether a worker is an employee or an independent contractor. DRS will apply these factors, including but not limited to the following: Section 2: Right of Control Evaluation For each question, circle the yes or no column. Key: EE= Indicates Employee IC = Indicates Independent Contactor YES NO 1 Is the worker required to comply with detailed work instructions or procedures for when, where and how the worker must perform services? EE IC 2 Does the employer provide free training for the worker, or have the right to train the worker? EE IC 3 Are the worker's services an integral part of the employer's business operations? EE IC 4 Can the worker subcontract part or all of the r quired labor or services to another party? 3 AJ I1 iu.'/ > cLri 0.' v t i IC EE 5 Does the employer hire, supeNise and pay others to perform the same job as the worker? EE (IC 6 Does the worker hire, supervise and pay others on the job under a contract to furnish labor and materials? iv 0_ O -v.i .JC EE 7 Does the worker perform continuing services for the employer? EE 8 Does the employer set the worker's hours, routine or schedule? EE r 9 Is the worker required to devote his or her full time to the employer's business? EE IC 10 Does the employer require the worker to perform services on the employer's premises? EE430 11 Does the employer require the worker to perform services in a set sequence? EE IC ) 12 Is the worker required to provide regular, oral or written reports to the employer? EE ttliP 13 Is the worker paid by the hour, weekmonth? EE IC 14 Does the employer reimburse the worker for job-related expenses? h I,t`'`e M, '74EE Cl9) 15 Does the worker furnish tools and materials necessary for the services? `) EE DRS MS 344(R 5/09) Page 1 of 2