Contractor Safety Variance Request Form

Contractor Safety Variance Request Form
Submit this form to request approval for a variance from standard site safety requirements. Please complete all sections accurately.
Contractor/Company Name
Contact Person Full Name
First NameLast Name
Contact Email Address
example@example.com
Project or Site Name
Project or Site Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Describe the Safety Requirement for Which a Variance Is Requested
Reason for Requesting the Variance
Risk Assessment: What Are the Potential Risks Associated With This Variance?
Proposed Mitigation Measures
Affected Work Dates
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: