THE UNIVERSITY OF TEXAS MEDICAL BRANCH

EMPLOYEE/INDEPENDENT CONTRACTOR VERIFICATION FORM

Instructions
A.  General: Please review and complete the below Questionnaire prior to contracting for services with an INDIVIDUAL OR SOLE PROPRIETOR. Completion of the Questionnaire is required to assist in determining the appropriate process for contracting pursuant to UT System and UTMB policies and Internal Revenue Service (IRS) regulations and guidelines.
B.  Processing:
B.1 If any of your responses to the Section III (Classification Guidelines) of the Questionnaire are "NO", the individual does not qualify as an Independent Contractor and his or her services may only be obtained via employment. Please contact Human Resources at extension 2-8699
B.2 If processing a Non-PO Voucher (NPO) transaction, forward this completed form, that has been signed by the department administrator or department head, to Accounts Payable, Route 0901, with any other required documentation.
B.3 If processing a Small Order System (SOS) transaction, please forward this completed form, that has been signed by the department administrator or department head, to Logistics /Acquisition, Route 0905.
B.4 If processing a non-SOS Requisition, this form will also need to be completed in coordination with Acquisition staff.
Please contact the Logistics-Help Desk at extension 7-8000 should you have any questions regarding the completion or routing of the form.

QUESTIONNAIRE

I. ______
(Individual’s/Sole Proprietor’s Name)
Complete if nonresident alien: Visa Status ______Home Country ______
II. Contracting with a current or former employee of the University of Texas System
or a State of Texas Agency YES NO NA
A. This individual currently does not work for UTMB or a UT System component. If No, click here. ______
B. During the twelve (12) months preceding the date when the services will commence this individual
was not employed by UTMB, a UT System component or a State of Texas Agency. If No, click here. ______

III.  Classification Guidelines

YES NO NA
A. It is anticipated that this individual will not be hired by UTMB immediately
following the completion/termination of the services. ______
B. The individual will not be given detailed and specific instructions by UTMB personnel
regarding when, where and how the services should be performed. ______
C. UTMB personnel will not provide the individual with training to enable him or her
to perform the services. ______
D. The individual is at risk of realizing an economic loss from failure to deliver the agreed-upon
services with the agreed-upon time frame. ______
E. Teacher/Lecturer/Instructor (answer only if applicable)
1. The individual is a “guest Lecturer” (e.g. an individual who lectures at only a few class sessions)? ______
.
2. a. The individual is teaching a course for which students will not receive credit toward a
University degree. ______
b. The individual provides the same or similar services to other entities or to the general
public as part of the trade or business. ______
3.  In performing instructional duties, the individual primarily will use course materials that are
created or selected by the individual. ______

F. Researcher (answer only if applicable)

1. The individual will serve in an advisory or consulting capacity with a faculty member or
employee (i.e., the individual will be working with” the faculty member or employee in a
“collaboration between equals” type arrangement). ______

To the best of my knowledge, the above questions have been answered accurately:

1

Revision 2.1; eff. 08/18/06