SUTTER HEALTH CENTRAL



SUTTER HEALTH SACRAMENTO SIERRA REGION

INDEPENDENT CONTRACTOR CHECKLIST

The following list contains the critical factors used by the Federal and State agencies to determine whether an individual is an independent contractor (IC) or an employee (EE).

Complete the following checklist by marking either “yes” or “no” for the appropriate response to the statement. This form is designed to evaluate whether a person is an independent contractor or an employee. If there are questions regarding IC status please contact the Human Resources department.

Sutter Medical Center, Sacramento Independent Contractor

Dept.: Medical Staff/CME Services Legal Name: David Marx

Facility: Sutter Medical Center DBA: Outcome Engineering

Completed by: Kristine Wakefield, CPMSM, CPCS Bus. Address: 2200 W. Spring Street, Ste. A

Project summary: City/St./Zip: Plano, TX 75023

Business Phone: (214) 778-2010

SSN/Tax ID:

Yes No

1. X Is paid by the job or project, not for time worked, such as by the hour or month.

2. X Offers services to the general public, not just Sutter (check those which apply):

__Has a business license (and fictitious name statement if appropriate) – attach copy.

__Has a professional license (if required) – attach copy.

__Advertises services in newspapers, yellow pages, etc.

__Lists services in a business directory.

__Has an office, materials, and supplies.

__Hires, directs, and pays assistants or employees.

__Carries business liability insurance – attach copy.

__Carries workers compensation insurance – attach copy.

3. X Works for multiple firms, and receives a small proportion of annual pay from Sutter.

4. X Can make an entrepreneurial profit or loss; Check those which apply:

X Individual has substantial continuing and reoccurring business liabilities (loans, bills, rent,

etc. – do not include personal expenses).

Individual files Schedule C (tax return).

X Individual has agreed to perform specific job(s) for agreed upon prices, in advance.

5. X Pays own business expenses (e.g.: telephone, office supplies).

6. X Has own tools and equipment (e.g.: computer, desk, hand and power tools).

7. X Has significant investment in his/her own business; the individual should be able to show

that they are in business and have put forth substantial capital, time and money to be in this

profession.

8. X Has time to pursue other work as an independent contractor; if the individual is working

full-time for any one company, it is hard to show that they had time to pursue other work.

9. X Sets own work hours.

10. X Decides where to work. If Sutter is to provide facilities for the individual to use, the person

is to pay fair market value for the use of the facility.

Yes No

11. X Work is not closely supervised; usually, the job specifications for the end result will be

furnished.

12. X Is not required to personally provide the services. The individual may hire other people to

assist or do the actual work.

13. X Receives no professional training from Sutter to perform work.

14. X Service performed is non-essential, that is, the success or continuation of services provided

by Sutter do not reside with this individual or the individual’s firm.

15. X Has no continuing relationship; Typically, the “relationship” is less than three to six months

in length. The person is only here to do a specific job or project.

16. X Limited right to terminate; The individual will not be terminated as long as the individual is

providing the services which meet the contract specifications.

17. X Receives no compensation for non-completion; The individual is responsible for the

satisfactory completion of the job and may not be compensated if the individual fails to

complete the job or assignment.

18. X Services are not currently routinely performed by anyone in any department.

19. X Is not a current or previous employee of any Sutter organization (if not, answer yes).

20. X Has no conflict of interest (e.g. has a spouse, relative, business associate, or any other

person which might create a conflict of interest, working for Sutter-if not, answer yes).

If there is a conflict of interest, who and where does the current Sutter employee(s) work?

Name and Department:

ANALYSIS OF COMPLETED CHECKLIST:

The potential independent contractor has reviewed this checklist and affirms that the information contained herein is true and correct.

_____________________________ _____________________________________ _______

Signature Legal Name/DBA Date

The Sutter representative holding the title of manager or above has reviewed this checklist and determined that this individual meets the criteria for an independent contractor.

_____________________________ ________________________ ________ _______

Signature Title Phone Date

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