BPA F 4220.08e Supplier Safety Program Variance Request

BPA F 4220.08e

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

(07-2023)

OMB Control Number 1910-5190
Expires: XX/XX/XXXX

SUPPLIER SAFETY PROGRAM VARIANCE REQUEST

Page 1 of 2

Purpose of form: this form is used by BPA to grant contractors who are registered in ISN a variance from the contractor safety performance
metric (letter grade). This form will assist in ensuring all required supplier contractual elements have been considered and reviewed. Please
submit requests via email to the Contractor Safety Committee inbox, [email protected] .
Name of Requestor

Date

Initial Facility or Site

Initial Project Title

Project Manager (Name)

Contracting Representative (COR) (Name)

Type of Project

Describe the Scope-of-Work in Detail

SUPPLIER CONTACT INFORMATION
(Provide contact information for the company or individual this form is intended to cover.)
BPA Contract Number

Company Name

Primary Contact

Address

Contact Numbers:

Office Phone Number

Office Fax Number

Work Cell Phone Number

Small Business
Yes

No

Attach all required written programs, training, or other records submitted by supplier that have been reviewed by the appropriate SME. List
each document below separately. Attach additional information to this form if needed.
1.
2.
3.
4.
5.
6.
7.
REASON FOR REQUESTING VARIANCE
(To be filled out by supplier.)
Deficiency (for example, OSHA Citation is incorrect)

Evaluation

Notes:

File Code: DW-1200; Retention: Destroy 7 years after the related records have been downgraded, transferred, or destroyed.

BPA F 4220.08e

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

(07-2023)

OMB Control Number 1910-5190

SUPPLIER SAFETY PROGRAM VARIANCE REQUEST

Page 2 of 2

Expires: XX/XX/XXXX

COMPLIANCE PLAN
Additional controls
used to ensure
appropriate
mitigation of
identified risk
factors (be specific).

1.
2.
3.
4.
BPA CONTRACTOR SAFETY COMMITTEE APPROVAL
(To be filled out by Contractor Safety Committee.)

Signing below means you agree that the contractor is approved for a variance and that the appropriate controls will be implemented to manage
business risks.
Has this supplier received a variance within the last three years?
Yes (if yes, explain below)
No

Approved Request Type:
ROLE

NAME

Approved

Rejected

BPA Wide

Project Specific
DATE

Need more information
EXPIRATION DATE

SIGNATURE

CSC Approving Official
LENGTH OF VARIANCE NOT TO EXCEED ONE YEAR FROM APPROVAL DATE
Additional Comments
(to be filled out by CSC Approving Official)
Notes:

Paperwork Reduction Act Burden Statement:
This data is being collected by BPA to grant contractors registered in ISN a variance from the contractor safety performance metric (letter
grade). This form will assist in ensuring all required supplier contractual elements have been considered and reviewed. Public reporting burden
for this collection of information is estimated to average 30 minutes (.5 hours) per response, including the time for reviewing instructions,
searching existing 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 1910-5190), 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 1910-5190), 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 Government-owned, contractor-operated facilities.
Submission of this data is voluntary.
File Code: DW-1200; Retention: Destroy 7 years after the related records have been downgraded, transferred, or destroyed.