INDEPENDENT CONTRACTOR REQUEST FORM
_______________________________________________________________________________________________________________
***IMPORTANT INFORMATION***
IF THE PROPOSED INDEPENDENT CONTRACTOR IS A CURRENT CSU, STATE OF CALIFORNIA, OR CSU AUXILIARY EMPLOYEE,
DO NOT PROCEED WITH THIS INDEPENDENT CONTRACTOR REQUEST FORM. THERE ARE ALSO RESTRICTIONS PLACED ON
THOSE WHO HAVE BEEN EMPLOYED BY THE STATE OF CALIFORNIA (INCLUDING THE CSU) IN THE PAST ONE TO TWO
YEARS. PLEASE CONTACT YOUR CAMPUS ENTITY HUMAN RESOURCES FOR FURTHER GUIDANCE.
IF THE PROPOSED INDEPENDENT CONTRACTOR IS DOING BUSINESS UNDER A COMPANY NAME AND THE PROPOSED
INDEPENDENT CONTRACTOR IS CONTRACTING OUT THE WORK TO COMPANY EMPLOYEES OR TO A 3RD PARTY, DO NOT
PROCEED WITH THIS INDEPENDENT CONTRACTOR REQUEST FORM. THE PROPOSED INDEPENDENT CONTRACTOR,
UNDER THIS STATUS WOULD NOT BE CLASSIFIED AS AN INDEPENDENT CONTRACTOR, THEREFORE, NO REVIEW WILL BE
REQUIRED.
▪ ALL INDEPENDENT CONTRACTOR (IC) REQUESTS MUST BE APPROVED BY HUMAN RESOURCES BEFORE WORK IS
PERFORMED.
▪ PLEASE ALLOW 5-7 BUSINESS DAYS TO RECEIVE A DETERMINATION ON THE IC REQUEST ONCE ALL REQUIRED
DOCUMENTS HAVE BEEN SUBMITTED TO HUMAN RESOURCES.
_______________________________________________________________________________________________________________
Campus Entity
CSUN
CSUN Foundation
The University Corporation
Associated Students
_______________________________________________________________________________________________________________
In compliance with Assembly Bill (AB) 5, which addresses the “Employment Status” of workers who claim to be Independent
Contractors and not employees, a review of the “employer-employee” relationship must be completed. The review requires a
detailed analysis of each situation’s unique circumstances. Because of recent changes in the law, past approval of an individual
as an independent contractor should not lead to a presumption that the same classification will be made again. Convenience
cannot be a determining factor for classification. It is important to understand that misclassification can result in serious financial
penalties and consequences for the campus.
Please complete this Independent Contractor (IC) request form signed by the appropriate administrator and email this form along
with any supporting documents to the appropriate Human Resources representative based on the following areas:
•
•
The University Corporation: [email protected]
•
Associated Students: [email protected]
A notification of the Contractor’s status will be sent to the Campus Entity once the IC request is reviewed. If approved, the
Campus Entity may proceed with processing their respective procurement process. If the IC request was not approved,
the Contractor is deemed to be an employee and the requestor shall contact their respective HR department.
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INDEPENDENT CONTRACTOR REQUEST FORM
City & State:
1. PROPOSED INDEPENDENT CONTRACTOR INFORMATION
Name:
(If applicable) Consultant’s Legal Business Name (includes doing business as):
Legal Business’ Street Address:
Contact Information (Phone and Email):
Partnership Corporation LLC Other
No If Yes, list license type:
Payment Amount Requested:
Check one (if applicable): Sole Proprietorship
Is the Independent Contractor Licensed? Yes
2. DEPARTMENT REQUEST DETAILS
Department:
Requested By (Name/Title):
Date Range:
Charge to: (Fund-Department-Program-Class-Project)
3. DESCRIPTION OF SERVICES/JUSTIFICATION
Please provide details outlining the proposed services (or attach a copy of the proposal):
4. ADMINISTRATOR REVIEW & AUTHORIZATION (must be signed by the appropriate administrator)
I hereby declare that the information provided in this document is true and correct and that I have sufficient knowledge of,
authority, and responsibility for the work to be performed under this contract to effectively make this certification.
Requestor Name:
Signature: Date:
Appropriate Administrator Name/Title:
Appropriate Administrator Signature: Date:
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INDEPENDENT CONTRACTOR REQUEST FORM
5. QUESTIONNAIRE
The following questionnaire is to be completed by the Requestor and will be used by Human Resources to determine if
the work can be conducted by an Independent Contractor.
YES NO
1. Will the worker be required to comply with the university/auxiliary provided instructions about
when, where, and how to work?
2. Will the worker be provided with instructions/training by the university / auxiliary regarding the
particular method or manner by which the work will be performed?
3. Is the work to be performed a regular part of university / auxiliary business/work?
4. Does the department or another department on campus have employees performing the same,
or similar, functions?
5. Will the worker be required to perform the work himself or herself?
6. Will the worker be hiring or supervising university / auxiliary employees?
7. Will the worker and the university / auxiliary have a continuing relationship, meaning that the
period of service will not be performed in a finite time frame?
8. Can the worker terminate his/her relationship without incurring a liability for failure to complete
the job?
9. Will the worker be able to hire and pay his/her own assistants?
10. Does the worker offer similar services to others as part of his/her own business?
11. Will the worker be allowed to work concurrently for other organizations/clients while working
for the university / auxiliary?
12. Will the worker be able to determine his/her own hours and priorities?
13. Will the worker be hired and paid to complete one specific job/project for the university
auxiliary?
14. Will the worker realize a profit or loss as a result of his/her services?
15. Will the worker provide his/her own tools or materials?
16. Did the worker retire/separate from the CSU / CSU Auxiliary fewer than two (2) years ago?
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INDEPENDENT CONTRACTOR REQUEST FORM
YES NO
17. Was the retired / separated employee in a policy-making position or an MPP?
18. Will the worker participate in the process of planning, negotiations, transaction, or any part of
the decision-making process?
19. Will the worker’s position be funded by a CSU contract?
20. Will the worker be responsible for the supervision of CSU / Auxiliary contracted employees?
21. Is the worker free from control and direction of the public agency in the performance of work?
22. Does the worker perform work that is outside the usual course of public agencies' business?
23. Is the worker customarily engaged in independently established trade, occupation, or business of
the same nature as the work performed for the public agency?
24. Is the proposed Independent Contractor currently employed by the State, CSU or a CSU
Auxiliary?
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INDEPENDENT CONTRACTOR REQUEST FORM
HUMAN RESOURCES REVIEW
Determination:
Independent Contractor Employee (Contact Human Resources for further guidance)
Comments/Notes:
__________________________________________ ________________________________________
Campus Entity HR Reviewer Signature & Date Date to Campus Entity
Upon notification of Independent Contractor status from Human Resources, please follow the procurement procedures
for the campus entity. Contact information for the campus entity procurement procedures is below:
• CSUN Procurement: [email protected]
• CSUN Foundation: [email protected]
• The University Corporation: [email protected]
• Associated Students: [email protected]
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