University of Melbourne Combined

How to use this Guide

This User Guide is a combination of guidance and workbook and is designed to be printed double sided (or alternatively print only odd or even pages). For each criterion, guidance material is on the even numbered page and the workbook is on the odd numbered page.

USER GUIDE

The guidance is set out as in the example below.

1.1.2 The health and safety policy is available to other parties, including regulatory authorities, suppliers, contractors, customers and those visiting the workplace.		Audit Criterion	Œ

Examples
O	Guidance to auditors and users	Guidance to Auditors & Users

	An electronic copy of the policy on the organization’s web page Policy contained in organization’s annual report Policy included in induction material Policy included in tender documentation	Examples of documents/ records	Ž

s	How are contractors advised about the health and safety policy?	Discussions or questions that may assist

P	Policy on display in reception/visitor areas	‘Walk around’ Observations at the workplace

Œ	The audit criterion is the only auditable component. The other information and examples (at points 2, 3, 4 & 5) are to provide information and assistance in understanding the criterion.
	Additional factors that auditors may need to consider when determining whether the system conforms to the audit criteria.
Ž	The examples of documents and/or records give guidance about some of the paperwork that would assist in meeting the requirements of the criterion. It must be noted however, that the examples are not suggested as the only or preferred ways of meeting the criterion, nor should they be interpreted as a list which all organizations must have. An organization may have different ways of meeting the requirements of the criterion and the examples should not detract from this.
	The examples of questions are included to help auditors determine whether an organization is meeting the requirements of the criterion. The questions are intended as a supplement only, and do not try to cover all aspects. It is expected that there are many questions that would be asked in addition to the questions listed here.
	The examples of walk around provide guidance about what might be observed in the workplace which would provide confidence that the organization is managing the requirements of the criterion. In a health and safety audit, these observations may be necessary to demonstrate that the management system is providing a particular level of safety. Again, it is noted that these examples are not intended to be a comprehensive list of items that might need to be checked in a particular workplace.

NB: The absence of an example of documentation, questions, or walk around information does not mean that there is no documentation to see, question to ask or observation to be made in the workplace. For example, for criterion 3.9.1 no walk around guidance is offered but due to the wide range of potential issues that could be observed in the workplace, there would be an expectation of significant workplace observation being required by an auditor auditing this criterion.

WORKBOOK

Workbook pages are provided for the recording of evidence. It is important to ensure that the relevant people are interviewed, and that where appropriate, the input of employees is sought.

The workbook pages should record information about the persons spoken with in relation to the criteria, the documents and records seen to assist in verification and the observations and comments that will be pertinent to assisting in the judgment of the standard of systems in relation to the criteria being assessed. By recording this information it should provide sufficient information to enable other persons, including persons that may conduct future audits, to understand the factors impacting on your decision making.

On the basis of the evidence collected, a judgment can then be made about whether the criterion is applicable to the organization and if so a rating is awarded. Usually this will be ‘conformance’ or ‘nonconformance’. There is also a rating of ‘not able to be verified’. The definitions for each of these are explained in the appendices.

Section A.1 Environment, Health and Safety Policy

EMS 4.1

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The organization shall establish, document, implement, maintain and continually improve an environmental management system in accordance with the requirements of this International Standard and determine how it will fulfil these requirements.

The organization shall define and document the scope of its environmental management system.

EMS 4.2

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

Top management shall define the organization's environmental policy and ensure that, within the defined scope of its environmental management system, it

a) is appropriate to the nature, scale and environmental impacts of its activities, products and services,

b) includes a commitment to continual improvement and prevention of pollution,

c) includes a commitment to comply with applicable legal requirements and with other requirements to which the organization subscribes which relate to its environmental aspects,

d) provides the framework for setting and reviewing environmental objectives and targets,

e) is documented, implemented and maintained,

f) is communicated to all persons working for or on behalf of the organization, and

g) is available to the public.

OHSMS 1.1.1

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

Senior Management in consultation with all employees and/or their representatives shall define and document its policy for, and commitment to occupational health and safety. The policy shall be endorsed and supported by the most senior person within the organization such as the Chief Executive Officer or Managing Director. The health and safety policy shall include a commitment to:

a) The risk management process and ensure consistency with the nature of workplace activities and scale of health and safety risks;

b) Comply with relevant health and safety legislation and other requirements placed upon the organization or to which the organization subscribes;

c) Establish measurable objectives and targets for health and safety to ensure continuous improvement aimed at elimination of work related illness and injury;

d) Provision of appropriate health and safety training to all employees;

e) The consultation process to ensure all employees are included in the decision making processes impacting on workplace health and safety;

f) The dissemination of health and safety information to all employees, contractors, labour hire employees and visitors to the workplace;

g) Effective implementation of the health and safety policy.

Policy provisions shall be implemented consistently in all areas of business activity and on all sites where business activities are undertaken.

OHSMS 1.1.2 [NAT]

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The health and safety policy is available to other parties, including regulatory authorities, suppliers, contractors, customers and those visiting the workplace.

OHMSMS 1.1.3 [NAT]

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The health and safety policy is maintained and reviewed periodically to ensure it remains relevant and appropriate to the organization’s health and safety risks.

Evidence Checklist – Corporate Management Systems & Implementation
		2.2. New. Occupational Health and Safety Policy
1.1.1		The current OHS Policy meets the requirements of the criterion.
1.1.1		The current OHS Policy endorsed by University council.
1.1.1		Evidence of consultation process prior to endorsement of current OHS Policy.
1.1.2	P	Current Health and Safety Policy on the University web site
1.1.3		Records of management review meetings that record discussion of policy which consider legislative change, industry technology and business focus.
1.1.3		Policy review dates following legislative, organisational changes or scheduled review date.
1.1.3		Health and safety and associated policies containing dates of latest and proposed reviews.
1.1.3		Health and safety policy reflects the present management structure and the current allocation of responsibilities

Evidence Checklist – Local Management Systems & Implementation
1.1.1		Information about access to the health and safety policy provided to: a) new staff via HR induction guide lines b) visitors and others via visitor information guides
1.1.1	s	Can Local Area’s senior management (eg Dean, FGM, VP, and HoD) explain the objectives of the health and safety policy?
1.1.2		Evidence of communication of OHS Policy to contractors and those working on behalf of the University (eg volunteers/students) engaged by the local area.
1.1.2	P	Current Health and Safety Policy displayed in reception areas and notice boards of Local Area

Observations and comments

Section B.1 Legal requirements and practical guidance

EMS 4.3.2

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The organization shall establish, implement and maintain a procedure(s):

a) to identify and have access to the applicable legal requirements and other requirements to which the organization subscribes related to its environmental aspects, and

b) to determine how these requirements apply to its environmental aspects.

The organization shall ensure that these applicable legal requirements and other requirements to which the organization subscribes are taken into account in establishing, implementing and maintaining its environmental management system.

OHSMS 2.1.1

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The organization identifies and monitors the content of all health and safety legislation, standards, codes of practice, agreements and guidelines relevant to its operation.

OHSMS 2.1.2

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The organization’s procedures, work instructions and work practices reflect the requirements of current health and safety legislation, standards, codes of practice, agreements and guidelines.

OHSMS 2.1.3

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

All personnel in the organization are advised of, and have ready access to, current relevant health and safety legislation, standards, codes of practice, agreements and guidelines.

OHSMS 2.1.4

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The organization and/or individual satisfy legal requirements to undertake specific activities, perform work or operate equipment including any:

a) license;

b) certificate of competency;

c) notification;

d) registration;

e) approval, exemption; and/or

f) other relevant requirements.

OHSMS 2.1.5

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

Changes to health and safety legislation, standards, codes of practice, agreements and guidelines generate a review of existing procedures.

Evidence Checklist – Corporate Management Systems & Implementation
		Minutes of meetings that record discussion of new requirements.
		Guidelines for Review of Environment Management System: Legal & Other Requirements
	P	Current corporate health and safety information maintained at an accessible location.
		EHS legal requirements matrix – Risk Register
		Corporate Guidance Material: EHS licensing and registration requirements register.
		Copy of radiation licenses/permits
		EHSM 10.1 New. EHS Procedure Writing, requiring reviews of procedures and work instructions in response to new information.
		Corporate procedures and work instructions that reference the requirements of current legislation, standards, codes, agreements and guidelines
	P	How does the organisation undertake the systematic check of legislative changes and updated standards or codes to identify whether any alterations are needed to the current methods of works process?
		A documented procedure that specifies how health and safety legislation and other relevant information is identified and maintained. - EHSM procedure 4-1 New EHS Legal Requirements
		Associated responsibilities allocated in job descriptions: Manager EHS Systems and Programs EHS Adviser
		Access to subscription services that monitor legislative changes and issues updates or bulletins: · Safety Law · SAI Global - Australian Standards
2.1.3	P	A library of health and safety resources including Acts, Regulations, Codes and Standards.
2.1.3	P	Access to legislation through: · Victorian Legislation website (Workplace verification) · EHS Advisory Staff · University of Melbourne Library subscription services eg. Lawlex, Lexis Nexis (refer 2.1.1)
	s	Organisational representation at industry association meetings: · SIA · AUSA · WorkSafe Education Stakeholders Forum · Central Safety Group
	s	Does the organization correspond or regularly connect with legislators and/or contribute to emerging health and safety standards and issues in the industry?
	P	Access to Australian Standards through UoM Library Supersearch Database
		EHSM 11.1.2.New. Hazardous Substances EHSM 11.1.4.New. Poisons and Drugs EHSM 11.2.New. Biological Risk EHSM 115.New. Ionising Radiation EHSM 11.14.2.New. Plant Regulations EHSM 11.16. New. Confined Spaces EHSM 11.18. New. Asbestos Management EHSM 11.20.New. Cooling Tower Management

Evidence Checklist – Local Management Systems & Implementation
		Local area procedures and work instructions that reference the requirements of current legislation, standards, codes, agreements and guidelines
	P	Current local health and safety information maintained at an accessible location.
	s	Can employees nominate the location or contact person for accessing health & safety information?
		list of the applicable site licensing or registration requirements with matching records
		Register or record of license holders.
		List of plant requiring registration and copies of current registrations.
		Copies of licenses.
		Correspondence from legislative authorities.
	P	Licenses/certificates carried by users of mobile plant.
	P	Registration certificates displayed on plant.
	s	Can local supervisors or managers explain how health & safety licenses and registrations are maintained?
	s	Can relevant employees nominate the health & safety legal requirements for specific work or equipment?
		copies of procedures and work instructions which reference current legislation, standards and codes
		Records where the organization’s current work practices have been reviewed against the latest industry or legislative requirements.
	s	How does the local area supervisor or manager know whether any alterations are needed to the current methods of works process?
		Local area procedures and work instructions that reference the requirements of current legislation, standards, codes, agreements and guidelines
	s	Can local supervisors & managers explain how the local area ensures that procedures meet relevant requirements?

Observations and comments

Section B.2 Objectives and targets

EMS 4.3.3

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The organization shall establish, implement and maintain documented environmental objectives and targets, at relevant functions and levels within the organization.

The objectives and targets shall be measurable, where practicable, and consistent with the environmental policy, including the commitments to prevention of pollution, to compliance with applicable legal requirements and with other requirements to which the organization subscribes, and to continual improvement.

When establishing and reviewing its objectives and targets, an organization shall take into account the legal requirements and other requirements to which the organization subscribes, and its significant environmental aspects. It shall also consider its technological options, its financial, operational and business requirements, and the views of interested parties.

The organization shall establish, implement and maintain a programme(s) for achieving its objectives and targets. Programme(s) shall include the:

a) designation of responsibility for achieving objectives and targets at relevant functions and levels of the organization, and

b) means and time-frame by which they are to be achieved.

OHSMS 2.2.1

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

Health and safety objectives and targets consistent with the organization’s health and safety policy are documented, are appropriate to the organization’s activities and consider:

a) legal requirements;

b) standards and codes;

c) health and safety hazards and risks;

d) available technologies;

e) agreements and guidelines;

f) operational requirements; and

g) the views of interested parties.

OHSMS 2.2.2 [NAT]

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

Specific health and safety objectives and measurable targets have been established for all relevant functions and levels within the organization.

OHSMS 2.2.3 [NAT]

Rating
o Conformance	o Not able to be verified	o Not Applicable
o Nonconformance	o Requires Correction	o Scope for Improvement

The organization sets health and safety performance indicators that:

a) are consistent with its objectives and targets;

b) include actions taken to prevent injury and illness; and

c) meet legislative obligations.

Evidence Checklist – Corporate Management Systems & Implementation
		EHSM 5.1. New. EHS Management Plans
		EHSM 3.1. New. EHS Risk Management
2.2.1		Minutes of meetings which record discussion about the selection of suitable health and safety objectives and targets.
2.2.1 2.2.2 2.2.3		Health and safety objectives and targets are linked with risk rankings set out in the Risk Register
2.2.1	s	Who was involved in the setting of the objectives and targets?
2.2.1 2.3.1		Health and safety objectives and targets reference: · legal requirements; · standards and codes; and · technical requirements.
2.2.2		Minutes of meetings which record discussion of health and safety objectives and targets.
2.2.2	P	Health and safety objectives and targets available on the web.
2.2.2	s	How are objectives and targets measured?
2.2.2	s	Which functions have been determined as relevant for the development of objectives and targets?
2.2.2	P	Noticeboards displaying objectives and targets and information on progress to meet the objectives and targets.
2.2.2	s	What performance indicators have been set?
2.2.3		Procedures established and maintained for the use of statistical techniques to: monitor and evaluate the performance of the health and safety system; monitor and evaluate health and safety performance outcomes as a function of the organization's health and safety system.
2.2.3		Suitable performance indicators are included in performance appraisals.
2.2.3		Both positive and negative indicators are used when measuring progress against the health and safety program.
2.2.3		Hazard, incident or other health and safety data/records which match the issues covered in the health and safety objectives and targets.

Version:	1.0
Release Date:	22 May 2009
Release Status:	Endorsed for use
Approval Status:	Approved
Prepared by:	GM EHS