Form 68-0192 - Questionnaire For Determining Status Of Worker Page 3
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5Questionnaire for Determining Status of Worker
(Continued)
68-0192 (04-12)
Behavioral Control - Relationship
(continued)
Are reports required from the worker? ____Yes ____No
If “Yes”, attach examples: _____________________________________________________________________________
Who decides how the work assignments are completed? ____Firm ____Worker
What action can the firm take if the worker's services are not satisfactory? ______________________________________________
Who does the worker contact if problems or complaints arise? ________________________________________________________
Who is responsible for resolving the problems or complaints? ____Firm ____Worker ____Other
Does the firm carry worker's compensation insurance on the worker? ____Yes ____No
Can or does the worker employ assistants (helpers)? ____Yes ____No
Is the worker required to notify the firm of the hiring of assistants? ____Yes ____No
Are the assistants subject to the firm's control or supervision? ____Yes ____No
Can the firm discharge the assistants? ____Yes ____No
Is the firm required to carry workers' compensation insurance on the assistants? ____Yes ____No
Who pays the assistants or helpers? ____Firm ____Worker ____Other
Is the worker reimbursed if the worker pays the assistants or helpers? ____Yes ____No
Has the firm ever considered the worker an employee of the firm? ____Yes ____No
If “Yes”, explain: _____________________________________________________________________________________
Financial Control
Who provides the following? (If “Other”, explain)
Equipment ____Firm ____Worker ____Other_______
Tools ____Firm ____Worker ____Other_______
Supplies ____Firm ____Worker ____Other_______
Vehicle ____Firm ____Worker ____Other_______
Materials ____Firm ____Worker ____Other_______
Does the firm rent/lease equipment to the worker? ____Yes ____No
If “Yes”, what are the terms? (Attach a copy of the agreement) ________________________________________________
Does the worker pay for any expenses in performing services for the firm? ____Yes ____No
If “Yes”, list the expenses: _____________________________________________________________________________
What, if any, expenses are reimbursed by:
The firm ___________________________________________________________________________________________
Other party _________________________________________________________________________________________
How is the worker paid?
____Hourly wage ____Salary ____Piece work ____Commission ____Lump sum ____Other (Specify) ______________
Who does the customer pay? ____Firm ____Worker
If “Worker”, does the worker pay the total amount to the firm? ____Yes ____No
If “No”, Explain: ______________________________________________________________________________
Can the worker incur any financial risk or loss? (e.g., loss or damage of equipment, material, etc) ____Yes ____No
If “Yes”, explain: ____________________________________________________________________________________
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