OSHA Form 5-30-4 National Defence Variance Application

NATIONAL DEFENSE VARIANCE APPLICATION1
OMB Control Number: 1218-0265
Expires: 3/31/2025

Instructions: Please review the supplemental information and instructions Supplemental Information and Completion
Instructions prior to completing the variance application. For questions about this form or the variance process,
contact OSHA at [email protected]
Section I - Applicant Information

1. Applicant Company
Company Name:
Principal Address:
Street:
City:

State:

ZIP Code:

State:

ZIP Code:

2. Contact Information
a. Authorized Representative:
Company Representative's Name:
Title/Position:
Address (if different from the company's principal address):
Street:
City:
Telephone:

Fax:

Email:

b. Primary point of contact with the company (if different from the authorized representative):
Point of Contact Name:
Title/Position:
Address (if different from the company's principal address):
Street:
City:
Telephone:

Fax:

State:

ZIP Code:

State:

ZIP Code:

State:

ZIP Code:

State:

ZIP Code:

Email:

3. Multiple Site Addresses
a. Site Name:
Site address including:
Street:
City:
b. Site Name:
Site address including:
Street:
City:
c. Site Name:
Site address including:
Street:
City:
1Use of this form is voluntary.

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OSHA Form 5-30.4
June 2011

Section II - Support Information
4. Provide a detailed list of the standard(s) from which the applicant is requesting the national defense variance.

5. Explain in detail how the proposed variance, limitation, tolerance, or exemption is necessary and proper to avoid serious impairment
to the national defense.

6. Describe how the applicant informed its workers of the application and their right to petition the Assistant Secretary for a hearing.2

7. If the applicant is requesting an Interim Order to use the alternative method until OSHA renders a decision on the variance application,
attach a statement of facts and argument explaining why OSHA should grant such an Order.

2Examples of how the applicant may inform its workers include: (1) Giving a copy of the application to their authorized representative; and (2) posting a
statement giving a summary of the application and specifying where workers may examine a copy of it, at the place(s) where the applicant normally posts
notices to workers (or, instead of a summary, posting the application itself).

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OSHA Form 5-30.4
June 2011

8. The applicant certifies by the signature below that the information contained in the application is accurate and true to the best of the
applicant's knowledge.

Signature of the authorized representative:
Print name:

Date:

Paperwork Reduction Act Statement

OMB Control Number: 1218-0265

According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of
information unless such collection displays a valid OMB control number. Public reporting burden for this
collection of information is estimated to average 30 hours per response. This burden includes locating and
assembling information required to complete the variance application, informing affected workers of the
decision to seek a variance, completing the variance application, and assembling the application
documents, but does not include hosting an OSHA site visit. The obligation to respond to this collection is
voluntary. Information obtained from this form will be used to determine if a variance will be granted to
the applicant. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: U.S. Department of Labor, OSHA, Office
of Technical Programs and Coordination Activities, Room N-3653, Frances Perkins Building, 200
Constitution Avenue, N.W., Washington, D.C. 20210. OMB Control Number: 1218-0265.

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OSHA Form 5-30.4
June 2011

Supplemental Information and Instructions for Completing the
National Defense Variance Application
Section 16 of the Occupational Safety and Health (OSH) Act of 1970 (29 U.S.C. 651 et seq.) authorizes
national defense variances granting reasonable variations, tolerances, and exemptions from Occupational Safety
and Health Administration (OSHA) standards to avoid serious impairment of the national defense. If a national defense
variance is in effect for more than six months, employers seeking the variance must notify their workers, and employees
must be afforded an opportunity for a public hearing on the issues involved. An employer may apply for a national
defense variance by following the regulatory requirements specified by 29 CFR 1905.12. Only Federal OSHA may
grant national defense variances.3 Sections A, B, C, and D below provide a brief summary of these requirements,
detailed application form completion instructions, some common mistakes to avoid, and procedures and instructions
for submitting a national defense variance application to OSHA.
A. Summary of Requirements for Obtaining a National Defense Variance
An employer (or class or group of employers4) may request a national defense variance for a specific workplace(s). A
national defense variance authorizes employer(s) reasonable variations, tolerances, and exemptions from compliance
with the requirements of a standard when they can show that the proposed variance is necessary and proper to avoid
serious impairment to the national defense. In addition, the employer must notify employees of the variance application,
and of their right to petition OSHA for a hearing.
B. Instructions for Completing the National Defense Variance Application
Section I: Application Information
1. and 2. Self-explanatory.
3. Provide the address(es) of all the location(s) of employment where the applicant would implement the national
defense variance (if different from the company's principal address).
Section II: Support Information
4. through 7. Self-explanatory.
8. This form is to be signed by the applicant's authorized representative to certify that the information contained in
the application is accurate and true to the best of the applicant's knowledge. Also, enter the printed name of the
applicant's representative, and the date the authorized representative signed the application.
C. Reviewing the National Defense Variance Application
Carefully review the variance application, and ensure that:
1. The application is complete and contains detailed descriptions for each item in the form, including the name and
signature of the authorized representative;
2. The variance is not a request for a waiver from the requirements of a standard;

3See 29 CFR 1952.8(b), which states: "No action by a state under a plan shall be inconsistent with action by the Secretary [on a national defense
variance]."
4A class or group of employers in the same industry (such as members of a trade alliance or association) may apply jointly for a variance
provided an authorized representative for each employer signs the application, and the application identifies each employer's affected facilities.

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June 2011

3. The applicant is not seeking the variance from a "definition" or from a "performance" standard (i.e., a standard that
does not describe a specific action for meeting the requirements of the standard); and
4. If the application involves location(s) only in State Plan states, the employer must submit the application to Federal
OSHA.5, 6
D. Procedure for Submitting a National Defense Variance Application
Applicants must use the following procedure when completing and submitting an application for a national defense
variance to OSHA:
1. Complete this National Defense Variance Application form (printed or saved from OSHA's Variance Website),
or develop their version of the application that meets the regulatory requirements of 29 CFR 1905.12.
2. If completing a printed copy of the application form, use additional sheets when necessary to provide a full
and detailed response.
3. The employer, or an authorized representative of the employer, must sign the completed variance application.
4. Submit the original of the complete application, as well as other relevant documents,7 to:
By regular mail:
Assistant Secretary for Occupational Safety and Health
Director, Office of Technical Programs and Coordination Activities
Occupational Safety and Health Administration
U.S. Department of Labor
Room N-3655
200 Constitution Avenue, N.W.
Washington, D.C. 20210
By facsimile:
202-693-1644
Electronic (email):
[email protected]

5Private-sector employers in the following states and territories are under Federal OSHA authority for occupational safety and health purposes:
AL, AR, CO, CT, DC, DE, FL, GA, ID, IL, KS, LA, MA, ME, MO, MS, MT, ND, NE, NH, NJ, NY, OK, OH, PA, RI, SD, TX, WI, and WV. Territories:
American Samoa, Guam, Trust Territory of the Pacific Islands, Virgin Islands, and Wake Island.
Most private-sector employers in the following 22 states and territories are under the authority of an OSHA-approved state occupational safety
and health plan (State Plan states): AK, AZ, CA, HI, IA, IN, KY, MD, MI, MN, NC, NM, NV, OR, SC, TN, UT, VA, VT, WA, and WY. Territory: PR.
Addresses for these states are available on the OSHA web site at www.osha.gov. (These states and territory, as well as CT, IL, NJ, NY, and VI, also
provide coverage to public-sector employers under their state plans.
6Only Federal OSHA may grant a national defense variance. (See 29 CFR 1952.8(b).)
7Other documents may include photos, blueprints, drawings, models, reports, data, and other information and evidence necessary to describe
the proposed alternative and, to demonstrate the level of employee protection it provides.

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OSHA Form 5-30.4
June 2011