BPA F 1400.22a Other Utility/Contractor/Vendor Worker Access Request

U.S. DEPARTMENT OF ENERGY-BONNEVILLE POWER ADMINISTRATION (BPA)

BPA F 1400.22a
(09-2021)

OTHER UTILITY/CONTRACTOR/VENDOR WORKER ACCESS REQUEST

OMB Control Number:1910-5188
Expiration Date:

Privacy Act Statement:
Authority: 42 U.S.C. 7101, et seq. and Homeland Security Presidential Directive 12.

Purpose: BPA will use this information to identity proof and register applicants and determine the suitability of issuance of a DOE security badge.
Routine Uses: We do not disclose your information to third parties without your consent, except to fulfill the purpose for collection or as legally required. The information requested on this form is used
by BPA to document compliance with NERC CIP Standards, which requires that personnel having authorized cyber or authorized unescorted physical access to BPA’s Critical Cyber Assets, including
contractors and service vendors, have an appropriate level of personnel risk assessment, training, and security awareness. Records may be disclosed to: BPA employees and contractors as required
to complete job duties; to necessary parties if the security or confidentiality of the information in the records is compromised; and to the Department of Energy and other agencies to investigate
potential violations of law, and as necessary to minimize harm when information security has been compromised. Additional disclosures are listed in DOE-63 and GSA/GOVT-7.
Disclosure: Providing information on this form is voluntary. However, failure to provide the information requested herein will result in the denial of a security badge for the individual’s physical or cyber
access to certain BPA information and/or facilities.

Other Utility/Contractors/Vendors will not be permitted limited BPA unescorted access without the completion of a background check, required compliance training and providing a photo for
identification and badging purposes.
Other Utility Worker/Contractor/Vendor Companies are required to submit this completed form to: [email protected]
BPA’s TPC Office will send this form to Non-Government Employee Processing and Card Key Access. For recertification, please complete process again.

1. Other Utility/Contractor/Vendor completes
Check one:
Initial Request
Re-Certification
Legal Name of Other Utility Worker/Contractor/Vendor (Last, First, Middle Initial)
Position Title

Company Name

List of facilities needing access to:

Company Street Address (ID Badge to be sent to)

Company Phone Number

Company FAX Number

Will you require 24-hour access?
Yes

Has Other Utility/Contractor/Vendor Successfully Passed National
Criminal History Check?
Yes
No
If yes, Date Completed

No

Has Other Utility/Contractor/Vendor completed Annual Training? (Includes Security and CIPS
overview)
Yes
No
If yes, Date Completed

Has Other Utility/Contractor/Vendor Successfully Completed Personal Identity Verification (PIV)
Other Utility/Contractor/Vendor/Worker Photo attached to the form submittal
Yes

Yes

No

if yes, Date Completed

No

I hereby certify that the information provided regarding the Other Utility Worker/Contractor/Vendor is accurate and documentation to support this information will be
retained by Other Utility Worker/Contractor/Vendor employer and provide upon BPA’s request.

Required Signature - Manager from Other Utility/Contractor/Vendor Company
Name (Print or Type)

Signature of Manager from Other Utility/Contractor/Vendor Company

E-mail Address

Date

Paperwork Reduction Act Burden Disclosure Statement:
This data is being collected to ensure the security and safety of its employees, contractors, and facilities. The data you supply will be used by security personnel to provide employees access to specific physical sites. Public reporting burden for this collection of information is estimated to average .10 hours per response, including the
time for reviewing instructions, searching exiting data sources, gathering and maintaining that data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief
Information Officer, Enterprise Policy Development & Implementation Office, IM-22, Paperwork Reduction Project (OMB control number 1910-5188), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC,
20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (OMB control number 1910-5188), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of Management and Budget (OMB) before undertaking a collection of information directed to 10 or more persons of the general public, including persons involved in or supporting the operations of Governmentowned, contractor-operated facilities. Submission of this data is required.

File Code;SR-1165 Retention; Destroy 5 years after contractor relationship ends.