EMPLOYEE/CONTRACTOR QUESTIONNAIRE

WORKERS VERSION

1)

Were your hours of work controlled or could you have worked whatever hours you
wished? (Please attach a list of the hours worked each day.)
________________________________________________________________________
________________________________________________________________________

2)

How often was your work inspected? Daily? Weekly? More often?
________________________________________________________________________

3)

Who inspected your work?

Name: __________________________________________________________________
Position: ________________________________________________________________

4)

Did you supervise employees of the business or enterprise for which you worked?

Yes

5)

Were you required to submit time sheets?

Yes

6)

No

Was your time recorded on your behalf by the business for which you worked?

Yes

7)

No

No

What tools or equipment were supplied on your behalf by the business for which you
worked?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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8)

What tools or equipment did you supply free of charge?

________________________________________________________________________
________________________________________________________________________

What tools or equipment did you rent to the business for which you worked?
________________________________________________________________________
________________________________________________________________________

9)

Could you have taken other employment at the same time as you were working for the
business or enterprise in question, assuming that such work was available?

Yes

10)

No

If you had completed your work more quickly than scheduled would you have been paid
the same amount as if it had taken the scheduled length of time?

Yes

11)

No

If you had completed your work more slowly than scheduled would you only have been
entitled to receive the same amount as if the work had been completed on schedule?

Yes

12)

No

Were deductions taken from payments made to you for:

Income Tax:

Yes

No

Canada Pension Plan:

Yes

No

Unemployment Insurance:

Yes

No

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13)

14)

Did you yourself submit payments to the authorities for:

Income Tax:

Yes

No

Canada Pension Plan:

Yes

No

Unemployment Insurance:

Yes

No

Did you maintain your own Workers Compensation coverage?

Yes

15)

No

Could you have employed other workers, to be paid by yourself, to help you with the
work?
Yes

No

Did you employ anyone yourself on this job?

Yes

16)

No

Could you have provided a replacement for yourself without the express permission of
the business for which you worked?

Yes

17)

No

Do you operate a business performing the sort of work done?

Yes

No

If so, is that business a corporation?

Yes

No

If you operate a business, what is the name of that business?

______________________________________________________________________

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18)

Did you tender an amount for the job, or did the business for which you worked specify
the pay rate?
________________________________________________________________________
________________________________________________________________________

COMPLETED BY: ____________________________________________________________

Name (Please Print)
____________________________________________________________
Signature
____________________________________________________________
Date

PLEASE RETURN COMPLETED QUESTIONNAIRE TO:

LABOUR SERVICES
DEPARTMENT OF JUSTICE
GOVERNMENT OF THE NORTHWEST TERRITORIES
PO BOX 1320
YELLOWKNIFE, NT X1A 2L9

Fax #: (867) 873-0483

Phone #: (867) 873-7486

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