alberta government occupational health and · pdf fileoccupational health and safety: audit...
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In certification years certificate is mailed to
Audit Name
Audit Dates
ALBERTA GOVERNMENT
OCCUPATIONAL HEALTH AND SAFETY
AUDIT DOCUMENTMinistry Name
Approved December 3, 2013
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PURPOSE OF AUDIT:
Auditor Qualification COR
Baseline COR Maintenance
Certificate #:
Expiry Date:
A. EMPLOYER INFORMATION
Department or Organization Name:
Division or Worksite Name:(as entered on COR)
Employer WCB Account Number:
Employer WCB Industry Code:
Employer Contact Name:
Employer Contact Title:
Employer Address:(including postal code)
Telephone #:
Fax #:
E-mail:
GOVERNMENT OF ALBERTA
PARTNERSHIPS AUDIT COVER PAGE
Note: Audit Scope needs to be approved by the Public Service Commission before the Audit begins.
Audit Cover Sheet Page 1 of 2
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B. LEAD AUDITOR CONTACT INFORMATION
Lead Auditor Name:
Lead Auditor Department
or Organization Name:
Lead Auditor Address:
Telephone #:
Fax #:
Lead Auditor Signature
C. AUDIT TEAM MEMBERS INFORMATION (excluding Lead Auditor)
RoleDocumentation Review, Observation Tour,
Interviews, Report Writer
Employee I.D. #Name
GOVERNMENT OF ALBERTA
PARTNERSHIPS AUDIT COVER PAGE
Note: Audit Scope needs to be approved by the Public Service Commission before the Audit begins.
Audit Cover Sheet Page 2 of 2
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Audit Start Date:
Audit End Date:
Audit Report Completion Date:
Is Work at Peak Activities?
Yes No
Program
Location Sites Visited
1.
2.
3.
4.
5.
6.
7.
8.
9.
ACTIVITIES
Type Activities Here
ACTIVITIES
Type Activities Here
ACTIVITIES
Type Activities Here
AUDIT SCOPE
ACTIVITIES
Type Activities Here
ACTIVITIES
Type Activities Here
TOTALS
ACTIVITIES
Type Activities Here
ACTIVITIES
Type Activities Here
ACTIVITIES
Type Activities Here
ACTIVITIES
Type Activities Here
List ALL Program Areas, Worksites, Bldg. Name, Address, Floor Number Covered in the Scope of the Audit(Work areas and activities performed in work area)
(enter one location,
e.g. Edmonton, etc.)
(enter "x",
if applicable)
Audit Scope Sheet Page 1 of 2
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1.
2.
3.
4.
5.
6.
7.
8.
9.
Interviewed Interviewed Interviewed Interviewed Interviewed Interviewed
0 0 0 0 0 0 0 0 0 0 0 0
Number of Shift
Workers
FULL-TIME - If you are identified in IMAGIS as a Permanent employee and work at least 36.25 hrs/week
PART-TIME - If you are Temporary, Wage Reg, Wage 1450, Wage 2850 and/or work less than 36.25 hrs/week
If you have no direct reports you are a WORKER regardless of your classification
If work is regularly scheduled to occur at any time other than regular business hours (i.e. Monday to Friday
8:15-4:30) it must be properly identified as Shift Work
Full Time Part TimeNumber of Workers Number of
Managers
Number of
Supervisors
Number of
Executive Managers
Audit Scope Sheet Page 2 of 2
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YES NO N/A
1.0 OH&S MANAGEMENT
GoA Occupational Health and Safety Policy (1.3)
Contractor Selection Criteria (1.9)
Samples of Contracts that Identify Health & Safety Responsibilities (1.9)
Contract Compliance Reports, Related Inspection Reports, Incident Investigation
Reports, Follow-up Correspondence (1.9)
A1.0 HEALTH AND SAFETY COMMITTEES
Department Occupational Health and Safety Committee Terms of
Reference/Minutes (A1.1, A1.3, A1.7)
Workplace Health and Safety Committee Terms of Reference/Minutes (A1.2, A1.4,
A1.7)
Workplace Health and Safety Contact Person Records (A1.2, A1.4, A1.7)
2.0 HAZARD MANAGEMENT
Inventory of Jobs/Occupations (2.1)
Inventory of Tasks/Activities (2.2)
Completed Hazard Assessment Documents (2.3, 2.4, 2.14)
Written Safe Work Practices/Job Procedures/Codes of Practice/MSDS (2.7)
Lockout/tag out process and reporting forms/tags (2.17)
3.0 OH&S Training
Employee Training Records (A1.6, 2.13, 3.2, 3.3, 4.6, 5.8, 6.7)
4.0 INSPECTION
Written Policy/Procedure for Conducting Inspections Including Frequency (4.1)
Completed Inspection Checklists and Related Correspondence (4.2, 4.3, 4.5)
5.0 EMERGENCY PREPAREDNESS
Emergency Preparedness Plans (5.1, 5.2, 5.4)
Emergency Response Drill Reports/Follow Up Records (5.7)
DOCUMENT LIST
The documents listed below are required to verify information related to the specific audit questions in brackets.
The completed checklist indicates the documents have been reviewed during the audit.
Documentation Review
Document List Page 1 of 2
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YES NO N/A
6.0 INCIDENT MANAGEMENT
Incident Reporting and Investigation Procedure (6.1)
Completed Supervisor's Incident Investigation Reports (6.3, 6.4)
Incident/Injury Statistical Reports (6.5)
7.0 PROGRAM EVALUATION
Occupational Health and Safety Annual Plan (7.1, 7.3)
Previous Audit Report for information (7.1)
Observation Tour
Other documents need to be assessed during the audit observation tour to verify the specific audit questions in brackets.
Occupational Health and Safety Legislation, and other legislation as required (1.2)
Meeting minutes for the Workplace Health and Safety Committee or Contact (A1.5)
Administrative Controls such as Safe Work Practice or Procedures, Codes of Practice (2.8)
Document List Page 2 of 2
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EXECUTIVE SUMMARY
INTRODUCTION
Type Info Here.
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SCOPE
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PROGRAM STRENGTHS
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IMPROVEMENT OPPORTUNITIES
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RECOMMENDATIONS
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CONCLUSIONS
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Executive Summary Page 1 of 1
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D/I/OPoint
ValueScore
1.0 Occupational Health and Safety Management
1.1
Employees are familiar with relevant occupational
health and safety (OH&S) legislation. Verified by interviews with Executive Managers, Managers,
Supervisors and Workers
All employees should be able to explain OH&S legislated
requirements outlined in the Act, Regulation and Code that apply to
the work that they do. Other sources of legislation may also apply
to them such as the Alberta Fire Code or Building Codes,
Transportation of Dangerous Goods etc. They must be able to
also explain how this legislation applies to their work.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (all) 0-10
1.2
Health and safety legislation is available to
employees at all workplaces.Verified by observation of the workplaces
Current versions of Alberta’s Occupational Health and Safety Act,
Regulations and Code must be available to all employees. If the
legislation is available electronically employees must be able to
demonstrate how they access it. A reliable source of internet
service must be present in order for the online access to be
acceptable.
All points are awarded if observations indicate current
legislation is available at all workplaces. Provide examples.
O 5
Auditor Notes / RecommendationsAudit Scoring
Audit Questions / Instructions
Element 1.0 OHS Management Page 1 of 6
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1.3
The health and safety policy for the Government of
Alberta is available at all workplaces. Verified by review of documentation
The Government of Alberta (GoA) Occupational Health and Safety
Policy is signed by the Public Service Commissioner and endorsed
by the President of the Alberta Union of Provincial Employees
(AUPE).
The policy is written in the GoA OH&S Program and must be
available in hard copy or online to employees at all workplaces.
All points are awarded if documentation is in place. Provide
examples.
D 5
1.4
Employees are aware of the health and safety
policy for the Government of Alberta. Verified by interviews with Executive Managers, Managers,
Supervisors and Workers
Employee responses should demonstrate an understanding that
the GoA OH&S Program is built collaboratively with the AUPE; that
everyone has a shared responsibility to follow the GoA OH&S
Program at their workplaces; and that health and safety practices
are integrated with business operations and individual activities.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (all) 0-5
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1.5
The Deputy Minister/Assistant Deputy Minister
demonstrates the Department's commitment to
health and safety with employees. Verified by interviews with Managers, Supervisors and Workers
Commitment to health and safety within the department may be
demonstrated through communications that outline approval and
communication of any department specific OH&S procedures and
practices; department OH&S goals and plans; by providing
leadership to executive management on health and safety
initiatives; and by communicating and recognizing department
results and employee accomplishments for health and safety
performance.
Interview responses should illustrate how the commitment of the
Deputy Minister, and Assistant Deputy Minister, to health and
safety has been demonstrated.
Initiatives by the Department Health and Safety Committee and the
policy statement from Question 1.2 are not included in this
question.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (m,s,w) 0-10
1.6
Health and safety responsibilities have been
assigned for all employees. Verified by interviews with Executive Managers
Specific tasks and activities related to the implementation of the
GoA OH&S Program and effective operation of health and safety
practices and procedures must be assigned to employees at all
levels within a business unit. Senior managers are accountable to
ensure employees have assigned health and safety responsibilities
and are measured on their performance.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (em) 0-5
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1.7
Employees at all levels of the organization are
familiar with their assigned health and safety
responsibilities. Verified by interviews with Executive Managers, Managers,
Supervisors, and Workers
Employees should be able to discuss their assigned health and
safety responsibilities and authorities included in their annual
performance plans, job descriptions and responsibilities outlined for
them in the GoA OH&S Program.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (all) 0-10
1.8
Workers receive information, and can provide
feedback, on health and safety issues. Verified by interviews with Workers
Employees must be able to describe methods in which they receive
health and safety information and how they can provide feedback
on the information they have received. Communication methods
may include minutes of staff meetings, incident bulletins, health
and safety newsletters, memoranda etc.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (w) 0-15
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1.9
There is a process in place to ensure contracted
employers fulfill their legislated responsibilities
under the OH&S Act, Regulation and Code. Verified by review of documentation
All employers are required to meet the responsibilities of health and
safety legislation. The nature of the contracted work may provide
different levels of risk, which may result in not all of the criteria
listed being required. A sample of contracts should be reviewed
which may be present under various terminology - i.e. Service
Agreements, Fee for Service, short form and long form General
Services etc..
The process will include:
• OH&S selection criteria for contracted employers; 5
• the contract must identify health and safety responsibilities of
contracted employers;
5
• a process to monitor health and safety performance for
contracted employers during the period of the contracted services
and to correct identified deficiencies;
5
• a process to evaluate any improvement opportunities for future
contracts
5
5 points are awarded for each criterion if documentation is
in place. If specific criteria are not required for low or
medium risk operations they may be eliminated through the
use of a “not applicable” and a full explanation must be
provided. High risk operations (as defined in the OH&S
Code, Schedule 2, Table 2) are evaluated for all four
criteria.
D
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1.10
Sufficient resources are provided by the employer
to implement and improve health and safety. Verified by interviews with Executive Managers
Department Deputy Ministers/Executive Managers have the
responsibility to allocate funds, time and human resources to
implement, maintain and evaluate the operation of the GoA OH&S
Program, Goal and Plans within the Department. Resources
include such things as the provisions of health and safety
professionals or expertise, funding made available to implement
controls identified in hazard assessment and control reports, or
funding to implement corrective measures or correct deficiencies
identified in investigation and inspection reports.
Points are awarded based on the percentage of positive
responses from employees interviewed.
Provide examples.
I (em) 0-10
1.11
Health and safety records are retained. Verified by review of documentation
Records must confirm that the standard forms contained within the
GoA OH&S Program are being used for documentation of health
and safety events at the workplaces. This will include Hazard
Management forms, Incident Management forms, and OH&S
Management forms. The workplace where the document
originated must have a completed version of the document. There
must be evidence that forms are being maintained according to
proper GoA OH&S Program retention schedules and maintain any
applicable levels of confidentiality.
Documentation of other events such as site specific workplace
inspections checklists, health and safety orientation checklists, and
records of emergency response exercises must also be retained.
All points are awarded if documentation is in place.
D 10
Element Total 105 0
Element 1.0 OHS Management Page 6 of 6
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A1.0 Health and Safety Committees
A1.1 There is a Department Health and Safety
Committee operating in accordance with the
Government of Alberta OH&S Program. Verified by review of documentation
Terms of Reference and meeting minutes must confirm the
existence of an operational Department Health and Safety
Committee.
The Terms of Reference must include an appropriate
representation of management/opted out or excluded and
bargaining unit representatives; executive sponsorship or
participation of an Executive Team member on the committee
must also be documented; and outline the frequency at which
meetings will be held.
All points are awarded if documentation is in place.
D 10
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A1.2There is a Workplace Health and Safety Committee
(or Contact in lieu of a committee) operating at the
workplace in accordance with the Government of
Alberta OH&S Program. Verified by review of documentation
Terms of Reference and meeting minutes must confirm the
existence of an operational Workplace Health and Safety
Committee.
Terms of Reference must identify the workplaces included within
the scope of the committee, identify an appropriate representation
of management/opted out or excluded and bargaining unit
members and outline the frequency at which meetings will be held.
The number of non-union representatives cannot exceed the
number of union representatives on the committee.
Administrative workplaces may have a Workplace Health and
Safety Contact person acting in lieu of a committee.
Documentation may be present in the form of meeting minutes or
email communications between the contact and the Workplace
Manager. WHS Contacts are required to complete an activity
report annually.
All points are awarded if documentation is in place.
D 10
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A1.3
The Department Health and Safety Committee
performs its responsibilities in accordance with the
Government of Alberta OH&S ProgramVerified by review of documentation
Meeting minutes for the Department Health and Safety Committee
should confirm:
• issues addressed by the committee have a department wide
impact;
• the committee reviews annual evaluations of workplaces within
their scope;
• it reviews and supports the implementation of the Department’s
annual health and safety plan;
• members attend meetings regularly;
• minutes are approved by both management/opted out/excluded
and bargaining unit co-chairs (copies of the meeting minutes are
sent to the Deputy Minister, department Human Resource
Services and the AUPE)
• meetings occur at least three times per year.
All points are awarded if documentation is in place.
D 10
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A1.4Workplace Health and Safety Committees and
Contacts perform their responsibilities in
accordance with the Government of Alberta OH&S
Program. Verified by review of documentation
Meeting minutes for WHS Committees should confirm:
• meetings are occurring at the frequency defined within the Terms
of Reference;
• members, or alternates, are regularly attending the meetings;
• members are reviewing incident summary reports;
• members are participating in workplace inspections;
• the status of identified hazards and concerns discussed;
• other events planned and activities completed or their status;
• and are making recommendations to the Workplace Manager
that support the operation of the health and safety program within
the workplace.
• minutes are approved by both management/opted out/excluded
and bargaining unit co-chairs
Administrative workplaces require a Workplace Health and Safety
Contact person acting in lieu of a committee. Documentation must
show that Contacts are conducting annual inspections of their
workplace; accepting employees’ health and safety concerns and
utilizing the Issue Resolution Process as needed; reviewing
incident summary reports; and documenting any other health and
safety events or activities organized by the Contact.
All points are awarded if documentation is in place.
D 20
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A1.5
Meeting minutes for Workplace Health and Safety
Committees are maintained and are available to
employees at all workplaces.Verified by observation of the workplaces
Meeting minutes of the health and safety committee must be
available to employees. Original minutes and records of all
committee activities are maintained by the committee secretary.
They may be posted in a visible location or available electronically.
Points are awarded based on the percentage of locations
where meeting minutes were available compared to the total
number visited. Provide examples.
O 0-10
A1.6Workplace Health and Safety Committee members
or Contacts have taken the required health and
safety training. Verified by review of documentation
Training records of all committee members or contacts must show
they have taken the required training identified in the GoA OH&S
Program within their first year of appointment.
All points are awarded if documentation is in place.
D 5
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A1.7
Established timelines within the Issue Resolution –
Standard Process are met to ensure identified
issues are resolved in a timely manner.Verified by review of documentation
The issue resolution process begins after the employee has
discussed the concern with his/her supervisor and the supervisor
has failed to satisfy the employee’s concern; and the Workplace
Health and Safety Committee or Contact validates the concern as
a health and safety issue in accordance with the Issues Chart
within the GoA OH&S Program. Specific timelines, outlined within
the program, must be met in order to comply with the standard
process. Documentation must show timelines have been met.
Meeting minutes include the status of validated health and safety
issues and recommendations made to supervisors and managers.
Points are awarded based on the percentage of issues
resolved within the established timelines compared to the
total number of issues. Provide examples.
D 10
A1.8 Employees are familiar with the functions of the
Department and Workplace Health and Safety
Committees or Contact.Verified by interviews with Executive Managers, Managers,
Supervisors and Workers
Employees should be able to describe how the Department and
WHS Committees or Contact promote a healthy and safe
workplace. This should include identification of the members of
the committee or Contact who represents them; health and safety
activities that are organized by the committees or Contact; and the
methods used by the committees or Contact to communicate their
operations to the workplaces.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (all) 0-10
Element Total 85 0
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2.0 Hazard Management
2.1
Workplace specific Occupation Inventory forms
have been completed for all jobs and occupations. Verified by review of documentation
A detailed list of all employee jobs and occupations must be
available to compare to the staff listings for the area being audited.
The inventories must be specific to the workplace and must have
been reviewed within the previous three years.
Points are awarded based on the percentage of jobs and
occupations inventoried compared to the number required
as identified on staff listings or organizational charts.
Sampling is not acceptable for scoring this question.
D 0-25
2.2
Task Inventory forms have been completed for all
jobs and occupations in question 2.1. Verified by review of documentation
A list of job-specific tasks and activities must be available to
compare to the Occupation Inventory listings in Question 2.1
If no Occupation Inventory is available, or it is incomplete, the Task
Inventories must be compared to the staff listings or organizational
charts in order to verify they are complete. The inventories must
have been reviewed within the previous three years.
Ensure highway motor vehicle operation is considered if driving is a
frequent activity.
Points are awarded based on the percentage of Task
Inventory forms completed compared to the jobs and
occupations identified in 2.1 or to the staff listings. Sampling
is not acceptable for scoring this question.
D 0-25
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2.3
Hazard Assessment and Control Report forms
have been completed, and include all identified
tasks and activities, for each job and occupation at
the workplace. Verified by review of documentation
Hazard Assessment and Control Reports must demonstrate that
existing and potential health and safety hazards have been
identified for the tasks and activities listed in the Task Inventories
for each job or occupation. The reports must have been reviewed
within the previous three years.
Hazard Assessment and Control Reports must be available to
employees at all workplaces. If employees at a workplace are
unable to access the reports the score will be reduced accordingly.
Points are awarded based on the percentage of reports
completed compared to the total number required from the
inventories. Sampling may be necessary for scoring this
question.
The maximum score available for this question will be
determined by the total score awarded in question 2.2.
D 0-40
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2.4Health and safety hazards have been evaluated to
determine their level of risk and prioritized to
determine the order of importance to implement
controls. Verified by review of documentation
Hazard Assessment and Control Reports must demonstrate that a
process is in place to identify and prioritize the risk of health and
safety hazards for the tasks and activities listed in the inventories.
Degree of risk is based on an evaluation of the: Frequency of
employee exposure to the hazard; potential consequence of
exposure to the hazard; probability of an incident occurring.
Frequency x Potential x Probability = Risk
The risk analysis on the hazard assessment will assign an overall
rating for the degree of risk. The degree of risk must be prioritized
as High, Medium, or Low in order to establish the order of
importance to implement controls.
Hazard Assessment and Control Reports must be available to
employees at all workplaces.
All points are awarded if documentation shows the degree
of risk has been determined and prioritized. Sampling may
be necessary for scoring this question.
D 5
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2.5
All workers have participated in the identification
of applicable hazards and the implementation of
controls for their work and their workplace(s). Verified by interviews with workers
Interview responses must demonstrate that workers have
participated in the assessment, elimination and control of hazards
for their work and workplace. They should be able to describe the
process in which they participated in the development of their
hazard assessment(s), and/or that they reviewed the hazard
assessment for their job or occupation with the Hazard Assessment
Lead or their Supervisor, and it is directly applicable to the work
they do, the conditions under which they perform their work, the
equipment they use, and the controls in place at their workplace.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (w) 0-20
2.6 Engineering controls identified in Hazard
Assessment and Control Reports have been
implemented. Verified by observation of the workplaces
Engineering controls must be available to employees at the
workplace for which they have been identified in the Hazard
Assessment and Control Reports.
Implemented means the controls are in place and functional.
Points are awarded based on the percentage of engineering
controls that have been implemented at the workplace
where it is required compared to the number selected from
hazard assessments. Provide examples.
O 0-15
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2.7Administrative controls identified in Hazard
Assessment and Control Reports have been
written. Verified by review of documentation
Safe Work Procedures are written step by step instructions
required to safely perform a task from beginning to end.
Safe Work Practices are written guidelines that help in the safe
performance of a task that may not always be done in a specific
way.
A Code of Practice is required for any respiratory protective
equipment in use at the workplace, confined space entry and the
use of chemical substances and processes listed in Schedule 1,
Table 1 of the OH&S Code. Any NIOSH approved respiratory
protective equipment (i.e. N95 masks) in use at the workplace
require a Code of Practice.
Material Safety Data Sheets (MSDSs)are required for harmful
substances that are controlled products and/or may have an
adverse effect on employees or occupants of the facility. MSDSs
must have preparation or revision dates within the past three years.
Correspondence to the supplier requesting new MSDSs must be
on file if they are outdated. Correspondence must be dated within
the past three months of the audit dates.
Points are awarded based on the percentage of
administrative controls that have been written compared to
the number selected from hazard assessments. Provide
examples.
D 0-10
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2.8
Administrative controls are available to employees
at the workplace(s). Verified by observation of the workplace(s)
Written Safe Work Procedures/ Practices/Codes of Practice,
MSDSs or any other administrative control in the form of a written
document must be available to employees at the workplace for
which they have been identified on the Hazard Assessment and
Control Reports.
Points are awarded based on the percentage of
administrative controls that are observed at the
workplace(s) where it is required compared to those
selected from the hazard assessments. Provide examples.
O 0-15
2.9
Required Personal Protective Equipment (PPE)
identified in the Hazard Assessment and Control
Reports is available to employees for use. Verified by observation of the workplaces
Examples of common PPE are chemical or puncture resistant
gloves, respirators that meet NIOSH standards, hard hats that
meet CSA or ANSI standards, hearing protection that meets CSA
standards, foot protection that meets CSA, ASTM or NFPA
standards, eye protection that meets CSA or ANSI standards.
Other standards may be identified in the adopted code for that
activity.
Points are awarded based on the percentage of PPE
available to employees for use at the workplace where it is
required, compared to those selected from hazard
assessments. Provide examples.
O 0-15
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2.10Where Personal Protective Equipment (PPE) is
identified on the Hazard Assessment and Control
Report as a method of control, employees are
trained in the proper selection, use, care and
maintenance of the PPE. Verified by interviews with Managers, Supervisors and Workers
Employees must be able to describe the method of training they
received on the proper selection, use, care, and maintenance of
the PPE they are required to use.
Points are awarded based on the percentage of positive
responses from employees interviewed.
I (m,s,w) 0-15
2.11
Employees are using the controls for the identified
health and safety hazards on the Hazard
Assessment and Control Report. Verified by observation and interviews with Managers, Supervisors
and Workers
Interview responses must indicate that workers are using
engineering and administrative controls and PPE.
Points are awarded if observations indicate the controls are
in place, in use AND at least 70% of interviews are positive.
Provide examples for both techniques.
O AND I
(m,s,w)
15
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2.12
Managers and supervisors ensure the employees
use of engineering controls, administrative
controls and personal protective equipment. Verified by interviews of workers
Workers must be able to discuss how supervisors and managers
ensure the use of required controls at the workplace. The process
may be a formal disciplinary process that includes verbal reminders
and written reprimands, as well as recognition of positive
behaviors.
Points are awarded based on the percentage of positive
responses from employees interviewed.
Provide examples.
I (w) 0-15
2.13
Employees assigned as hazard assessment leads
have completed the required training. Verified by review of documentation
Training records for identified hazard assessment leads must show
that they have taken the required training since the implementation
of the revised GoA OH&S Program was released in 2009.
All points are awarded if documentation is in place.
D 5
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2.14The Hazard Assessment and Control Reports have
been completed by a hazard assessment lead in
consultation with employees who perform the
work. Verified by review of documentation and interviews with Executive
Managers and Managers
Employees trained as hazard assessment leads must have been
involved in the process of developing hazard assessments with
employees who perform the task or activity to ensure the report is
accurate. The involvement by the Lead must be present in the form
of a signature on the reports. The training of the Lead identified on
the reports must be verified by the audit team through review of
their training records.
All points are awarded if documentation is in place AND at
least 70% of interview responses are positive.
D AND I
(em,m)
10
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2.15
Hazard assessments are reviewed according to
Government of Alberta OH&S Program
requirements. Verified by interviews with Managers and Supervisors
Hazard assessments must be reviewed and revised according to
provincial OH&S legislation requirements, GoA OH&S Program
requirements and as a result of inspection or investigation findings.
The hazard assessment process must be repeated:
• when a new work process or new equipment is introduced;
• when a work process or operation change;
• when or before the construction of significant additions or
alterations to the workplace are made;
• when new hazards are identified, new controls are implemented
or controls for hazards are modified as a result of an inspection,
incident investigation, emergency exercise or emergency;
• and at least every three years.
Interview responses must demonstrate that managers and
supervisors are aware that hazard assessments are reviewed and
revised periodically, and give examples of when this has happened
at their workplaces due to the listed criteria.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (m,s) 0-30
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2.16
Equipment is maintained according to its
manufacturer's specifications. Verified by interviews with Supervisors and Workers
Equipment (for example: vehicles, mobile equipment, tools,
supplies, machinery, and sanitary facilities) must be maintained in
a condition that adheres to the manufacturer’s specifications and
will not compromise the health or safety of employees using or
being transported by them.
Schedules should be available for each piece of equipment and
based on the manufacturer’s specifications for maintenance and
servicing. These may be in the form of log books, inspection
checklists or databases.
Typical office equipment is not included.
Supervisors and workers should be able to describe how
equipment is maintained within their business unit.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (s,w) 0-15
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2.17There is a procedure in place to prevent the use of
defective equipment by employees. Verified by review of documentation and observation of the
workplaces
An important part of equipment maintenance is knowing the
process to report and record defective equipment that fails during
use, and isolating or controlling hazardous energy so that defective
equipment is not used by others. If tags, signs, locks or other
energy isolating devices are used, training must also be provided
to employees who are required to control and isolate the hazardous
energy of the defective equipment.
Documentation will include the process and may also include
reporting forms, new or used warning tags or a computerized
program or database.
Observation should identify examples of equipment or machinery
that has been removed from service. If none are readily available
the auditor should inquire regarding the process.
All points are awarded if documentation is in place AND the
procedure is observed to be in use. Provide examples for
both techniques.
D AND O 20
Element Total 295 0
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3.0
3.1
Employees receive health and safety orientation
that includes:
• Roles and responsibilities for workers,
supervisors and managers; locations of first aid
supplies and services; (0-5 points)
• Health and safety procedures such as: emergency
response; imminent danger; and reporting
incidents; (0-5 points)
• And it occurs within the first week of
commencement. (0-5 points)Verified by interviews with workers
Health and safety orientation must be provided by the supervisor of
both new employees, and employees who are assigned a new job
or who are relocated. Orientation for employees must provide
workplace specific information on health and safety topics that
include hazards specific to their assigned duties and workplace,
emergency response plans for their location, procedures for
emergency response, the location of first aid services and supplies,
incident notification procedures and responsibilities for health and
safety of the employee, their supervisor or manager and the
employer.
Points are awarded based on the percentage of positive
responses from employees interviewed.
Provide examples in each category.
I (w) 0-15
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Occupational Health and Safety Training
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Occupational Health and Safety Training3.2
Employees receive job specific health and safety
training before they begin a newly assigned task.
Managers (0-5 points)
Supervisors (0-5 points)
Workers (0-5 points)Verified by review of documentation
Health and safety training must be provided to all new employees
before they begin the task; and all employees before they start
working on a newly assigned task. This training must include the
review and revision (if needed) of hazard assessments for the task,
instruction specific to the employee’s tasks and work area, specific
requirements identified in and required by the hazard assessments,
instruction on safe work procedures, instruction on emergency
response procedures, how to use, select and maintain personal
protective equipment, how to safely use equipment, and instruction
on harmful substances employees will work with or be exposed to.
Training records must show that employees receive the training
specified on their Hazard Assessment and Control Reports to
safely perform their assigned duties. Other methods of identifying
training needs may include Safety Training Needs Assessment
templates or training matrices.
Points are awarded based on the percentage of employees
in each category who have received the required training
identified in hazard assessments, Safety Training Needs
Assessment templates or training matrices, compared to the
total selected. Provide examples in each category.
D 0-15
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Occupational Health and Safety Training3.3
Employees receive refresher training to maintain
certifications and remain competent to perform
their assigned tasks.Verified by review of documentation
Training records must show that employees who require refresher
training to maintain competency in their assigned duties receive the
required training. If the hazard assessment for that employee or
their tasks requires the training, then it must be maintained.
This may include seasonal refresher training, trade and skills
upgrading, review of safe work procedures or practices, WHMIS,
First Aid (3 years), Transportation of Dangerous Goods (Road 3
years, Air 1 year), control tactics, firearms, emergency vehicle
operations, defensive driving, confined space entry, respiratory
protective equipment.
Departments may establish their own timelines for refresher training
in these areas, if there is no legislated requirement, through the use
of a training needs assessment or matrix.
Points are awarded based on the percentage of employees
who have received the required training compared to the
number selected. Provide examples.
D 0-20
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Occupational Health and Safety Training3.4
Visitors and contractors receive health and safety
orientation to the workplace. Verified by interviews with Executive Managers, Managers,
Supervisors and Workers
Contractors and visitors require orientation to workplace health and
safety requirements. Topics include the location of first aid
supplies and services, emergency response procedures for the
facility, known hazards at the workplace.
External auditors are visitors to the workplace.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (all) 0-10
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Occupational Health and Safety Training3.5 Managers verify that employees have the
qualifications, training and experience to perform
their assigned tasks safely. Verified by interviews with Executive Managers and Managers
Management is responsible to ensure that employees have the
qualifications, training and experience to perform their assigned
duties safely with little or no supervision.
Qualifications may be earned through a formal educational
program, training course or a combination of education and
practical experience.
Training must be appropriate to the tasks and equipment that will
be performed or used and sufficient experience may be evaluated
during the length of time that work is performed under supervision.
The employer is ultimately responsible to ensure workers are
competent.
Management must be able to describe the process employees
undergo to ensure they are competent prior to performing assigned
duties unsupervised.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (em,m) 0-20
Element Total 80 0
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4.0
4.1Management has developed inspection schedules
for their operations and workplaces which meet or
exceed the requirements outlined in the
Government of Alberta OH&S Program Standard
Process.Verified by review of documentation
Managers must develop inspection schedules for their operations
and workplaces based on the frequencies given in this standard
process. The schedules should include inspection timeframes,
which operations and workplaces will be inspected, and who will
carry out each inspection.
The GoA OH&S program outlines minimum inspection frequencies
for types of workplaces based on continuous use. Workplaces
may require more frequent inspections during periods of high
activity, if the number of hazards related to equipment used and
activities at the workplace changes, or if the frequency or number
of incidents increases.
A department policy may also outline the frequency of inspections
for workplaces other than those in the GoA OH&S Program.
All points are awarded if documentation is in place.
D 15
4.2
Workplace inspections are conducted at the
frequency according to the Government of Alberta
OH&S Program requirements. Verified by review of documentation
Documentation must show that inspections are being carried out
at the frequency defined within the inspection schedules in
Question 4.1.
Points are awarded based on the percentage of inspections
that meet the required frequency.
D 0-10
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Inspections
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Inspections4.3 Inspections are conducted using a workplace
specific checklist. Verified by review of documentation
Equipment and site-specific checklists for operations and
workplaces within the business unit must be utilized. They
document observations and the corrective measures implemented,
and are the record of inspection. Inspections conducted by
Workplace Health and Safety Committees should have the
findings of their inspections also recorded in their meeting
minutes.
All points are awarded if documentation is in place.
D 10
4.4
Identified deficiencies on inspection checklists are
corrected. Verified by review of documentation and observation of the
workplaces
Managers are required to prioritize and verify that corrective
measures are immediately implemented for substandard
conditions and defective equipment identified during the inspection
and/or on the inspection report. The manager may delegate the
implementation of the corrective measure to the supervisor.
Points are awarded based on the percentage of deficiencies
selected from checklists that are observed to be corrected.
Provide examples
D
AND
O
0-20
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Inspections4.5Managers have signed completed checklists
verifying all identified corrective measures have
been implemented. Verified by review of documentation
Managers must review inspection checklists. They are signed off
by managers at a higher level than those conducting the
inspection.
Points are awarded based on the percentage of inspection
checklists signed by management compared to the total
number selected.
D 0-10
4.6 Employees assigned by management as
inspection leads have completed the required
training. Verified by review of documentation
Inspection checklists must identify employees conducting the
inspection. Comparison to training records must show that the
employee assigned as the inspection lead has completed the
required training since the GoA OH&S Program was revised in
2009.
All points are awarded if documentation is in place.
D 5
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Inspections4.7
Employees are familiar with the process to report
unsafe or unhealthy conditions and practices. Verified by interviews with Executive Managers, Managers,
Supervisors, and Workers
Employees must be able to describe a process in which they can
bring forward concerns regarding unsafe or unhealthy conditions
at their workplaces. All employees are encouraged to identify
concerns that may affect their own or their co-workers’ health and
safety. An employee who becomes aware of a health and safety
concern at the workplace shall immediately notify the supervisor.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (all) 0-20
Element Total 90 0
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5.0
5.1There is a written emergency response plan for
each type of potential emergency at each
workplace. Verified by review of documentation
Management is responsible to identify potential emergencies in
relation to the operations of the workplace, and to maintain current
written emergency response plans for each type of potential
emergency. The plans are developed and maintained in
consultation with employees. Plans must be reviewed and updated
annually or when changes at the workplace occur.
Workplaces must be assessed for their need for plans specific to
the following potential emergencies:
• Fire;
• severe weather;
• medical emergencies;
• hazardous materials release;
• workplace violence;
• suspicious persons;
• suspicious letters or packages;
• and other situations appropriate for the nature of the work being
performed (for example, working alone).
All workplaces within the scope of the audit must have site specific
procedures or a plan available to employees.
Points are awarded based on the percentage of documented
procedures in place in relation to the number required from
the list above. (0-20 points) Provide examples.
D 0-20
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Emergency Preparedness
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Emergency Preparedness5.2
The emergency response plan includes:
• The name and address of the workplace
• The type of potential emergency
• Alarm and Communication procedures (two-way
radios, personal trackers, cellular phones etc.)
• Emergency Phone numbers for emergency
services (police, fire, ambulance, utilities etc.)
• List of assigned emergency response personnel
trained to respond to the type of emergency to be
contacted
• Appropriate response procedures for employees,
visitors and contractorsVerified by review of documentation
The Facility Emergency Response Plan is a manual that provides
templates and guidance. Unless it is modified to be specific to the
workplace and the potential emergencies of the location and work
performed it will not be considered for the purposes of this
question.
Points are awarded in each category if documentation is in
place. (3 points each to a maximum of 18 points)
D 0-18
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Emergency Preparedness5.3
Employees understand their responsibilities for
each emergency procedure under the plans. Verified by interviews with Executive Managers, Managers,
Supervisors and Workers
Employees should be able to discuss the procedures for potential
emergencies at their workplace and their responsibilities related to
them. This should correspond with identified responsibilities within
the plans.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (all) 0-20
5.4 Workers have designated responsibilities for
emergency response procedures at their
workplace.Verified by review of documentation
Workers may be assigned by the manager as emergency
response personnel for a variety of potential emergencies at their
workplace. They may be involved in the annual review and update
of the emergency response plan; assigned to maintain first aid
equipment and supplies, and personal protective equipment, in
safe operating condition; assigned to complete emergency
response reports for each exercise and emergency; and must
complete assigned training, maintain the appropriate certifications
and participate in emergency response exercises. Documentation
should demonstrate worker participation, in a leadership role, in
the emergency preparedness processes and procedures at the
workplace.
All points are awarded if documentation is in place. Provide
examples.
D 5
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Emergency Preparedness5.5 Employees are trained on their individual
responsibilities for each potential emergency
identified in the plan. Verified by interviews with Executive Managers, Managers,
Supervisors and Workers
Employees must be able to describe the methods of training they
have had on the workplace specific emergency response plans in
order to maintain their competency to respond to emergencies.
Employees with designated responsibilities as emergency
response personnel (i.e. designated first aiders, rescue and
evacuation personnel) may have also received additional training
provided by outside service providers such as the fire department,
police department or independent resources for confined space
rescue or H2S events.
Points are awarded based on the percentage of positive
responses from employees interviewed.
Provide examples.
I (all) 0-20
5.6
Emergency exercises are held at least annually, for
each response procedure identified in the plans to
verify its effectiveness. Verified by interviews with Managers, Supervisors and Workers
Emergency exercises are required at all workplaces to maintain
the competency of the workplace occupants and emergency
response personnel to respond. Exercises could be documented
in Emergency Reports, staff meeting minutes where a plan was
reviewed, or specific meetings designed to review responsibilities
under the plans.
Examples given by employees during the interviews should be
verified by the audit team as part of documentation review.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I
(m,s,w)
0-20
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Emergency Preparedness5.7Deficiencies identified through emergency
response drills or actual emergencies are
corrected. Verified by review of documentation and observation of the
workplaces
Deficiencies identified during emergency response drills or during
actual emergencies have recommendations for corrective actions
outlined and they have been implemented.
Points are awarded based on the percentage of corrective
actions implemented compared to the number selected from
documentation. Provide examples.
D AND
O
0-15
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Emergency Preparedness5.8
First aid supplies and services are available
according to Government of Alberta OH&S
Program requirements. Verified by review of documentation and observation of the
workplaces
Check the current first aid legislation in the OH&S Code and verify
the requirements based on total number of workers at the
workplace(s) and the number of workers per shift.
Determine if the workplace is a low, medium or high hazard
workplace. Determine if the workplace is a close, distant, or
isolated workplace.
Confirm that there are adequate numbers of qualified first aiders
across all shifts and workplaces. Training records for employees
designated as first aiders, or requiring first aid training as identified
in their hazard assessment, must show that they have current
certification. Standard (2 day) First Aid is the minimum
requirement. All employees performing field work and lone
employees at a workplace must have Standard First Aid.
Compare the contents of all available first aid kits against the
requirements in the GoA OH&S Program using the criteria
determined above.
All points are awarded if documentation is in place AND first
aid supplies and services meet program requirements.
D AND
O
20
Element Total 138 0
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6.0
6.1There is a written procedure that requires the
reporting and investigation of occupational injuries
and illnesses. Verified by review of documentation
Two types of incident classifications require reporting and
investigation: incidents that involve employees and require
reporting based on near miss, treatment or loss, such as serious
incidents, medical aid or lost time; and incidents that have
reporting requirements based on the type of incident, such as
those that involve damage to GoA owned or leased property,
dangerous goods incident or environmental release incidents.
Incident investigations help determine what happened, how it
happened and what needs to be done to prevent the incident from
recurring without assigning blame or fault.
The written procedure for reporting incidents and the standard for
investigating all incidents is written in the GoA OH&S Program and
must be available at all workplaces.
All points are awarded if documentation is in place.
D 5
6.2Employees are knowledgeable of their
responsibility to report work-related incidents
according to the procedures in the Government of
Alberta OH&S Program. Verified by interviews with Managers, Supervisors and Workers
All employees are required to report all work-related incidents to
his or her immediate Supervisor, therefore they must know what
type of incidents that includes. Consider the nature of the work
being performed when evaluating examples provided.
Points are awarded based on the percentage of positive
responses from employees interviewed.
Provide examples.
I (m,s,w) 0-15
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Incident Management
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Incident Management6.3Investigations focus on the identification of
contributory and direct causes. Verified by review of documentation
Incident investigations help determine what happened, how it
happened and what needs to be done to prevent the incident from
recurring without assigning blame or fault.
Contributory causes are the underlying indicators detailing why an
incident occurred. Direct causes are the immediate cause of why
an incident occurred.
Contributory causes of an incident can relate to people, equipment
or other issues. For example, physical capability, knowledge and
skill or leadership and supervisions are considered people factors.
Purchasing, engineering and maintenance can all be examples of
equipment and material factors contributing to an incident. Other
contributory factors may include workplace conditions,
temperature extremes, improper or inadequate training, safe work
practices, workplace conditions, noise or visibility.
Direct causes are hazardous acts or conditions such as improper
lifting, modification of equipment from its manufactured design,
improper use of equipment for a purpose it was not designed, poor
housekeeping, inadequate guards or barriers, and inadequate or
improper procedures.
Points are awarded based on the percentage of
investigation reports that identify direct and contributory
causes compared to the total number selected.
D 0-20
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Incident Management6.4 Managers follow-up on work related incidents to
ensure appropriate corrective measures have been
identified and implemented. Verified by review of documentation and observation of the
workplaces
Managers are responsible to review incident details and causes
and assign corrective measures to be implemented. This action
must be completed by the senior manager in the event of a
serious incident, fatality or radiation incident.
Managers must verify that corrective measures have been
implemented and determine if the corrective measures: are
appropriate to eliminate or control the identified hazard; and have
not created additional hazards. Managers must also communicate
the investigation findings and the corrective measures being
implemented.
All points are awarded if documentation is in place AND
observations indicate that corrective measures selected
from investigation reports have been implemented. Provide
examples for both techniques.
D AND O 20
6.5
Incident statistics or records are maintained and
evaluated to identify trends. Verified by review of documentation
Identify examples of the statistics or summaries being maintained
for the area within the scope of the audit. Verify they are
analyzed, and any trends are identified. Trend analysis should
include recommendations and corrective actions to reduce the
incidence within the business unit.
The Workplace Health and Safety Committee or Contact is
responsible to review incident statistics or summaries of incidents
to identify causes and trends and to recommend incident
prevention measures when appropriate.
All points are awarded if documentation is in place. Provide
examples.
D 10
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Incident Management6.6
Managers and Supervisors are responsible for
incident investigations.Verified by interviews with Executive Managers, Managers and
Supervisors
Supervisors, or Managers in lieu of a supervisor, have the
designated responsibility within the GoA OH&S Program to
investigate all health and safety incidents. Interview responses
must indicate they are knowledgeable of this responsibility and
related processes.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I
(em,m,s)
0-10
6.7
Employees assigned as investigation leads have
completed the required training. Verified by review of documentation
All Supervisors are required to take training to conduct incident
investigations. Employees assigned as investigation leads must
also take the required training to conduct investigations.
Investigation reports must identify the person conducting the
investigation. Comparison to training records must show that
employees conducting incident investigations have completed the
required training since the GoA OH&S Program was revised in
2009.
All points are awarded if documentation is in place.
D 5
Element Total 85 0
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7.0
7.1
Management has developed an annual health and
safety plan for the workplace(s). Verified by review of documentation
Business units must establish a plan, with objectives and
measureable goals, to continuously improve health and safety of
their business operations. If plans have ongoing objectives then
indicators (targets and timeframes) must be found to demonstrate
the item(s) is in progress. Results and recommendations from the
last program evaluation must be incorporated into the development
of health and safety plans for the business units (not required if this
is the first audit for the workplace).
All points are awarded if documentation is in place.
D 30
7.2The health and safety annual plan has been
implemented. Verified by interviews with Executive Managers and Managers
Managers must be able to discuss the goals and objectives
contained within the health and safety annual plan and how they
have been implemented.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (em,m) 0-15
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Program Evaluation
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Program Evaluation 7.3
Workers are involved in the implementation of the
health and safety annual plan.Verified by review of documentation
The health and safety annual plan must identify the name(s) of
workers to whom a particular activity has been assigned. These
workers are responsible to assist in the implementation of the
health and safety annual plan for the business unit(s) being
audited.
All points are awarded if documentation is in place. Provide
examples.
D 10
7.4Employees are familiar with the annual health and
safety plan. Verified by interviews with Supervisors and Workers
Employees must be able to explain the goals and objectives
contained in the annual health and safety plan for their organization
(the units defined within the audit scope).
Points are awarded based on the percentage of positive
responses from employees interviewed.
Provide examples.
I (s,w) 0-20
Element 7.0 Program Evaluation Page 2 of 3
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D/I/OPoint
ValueScore
Audit Questions / Instructions
Audit Scoring
Auditor Notes / Recommendations
Program Evaluation 7.5 Supervisors and workers are evaluated on and are
accountable for their health and safety
performance. Verified by interviews with Supervisors and Workers
Supervisors and workers must be able to explain the methods used
to evaluate their performance of assigned health and safety
responsibilities. This may include annual performance appraisals,
letters of commendation, positive behavior reinforcement, discipline
for non-performance etc.
Points are awarded based on the percentage of positive
responses from employees interviewed.
Provide examples.
I (s,w) 0-10
7.6All levels of management are evaluated on and are
accountable for the successful implementation of
the health and safety program within their
business units. Verified by interviews with Executive Managers and Managers
Managers are the GoA’s representative for the purposes of
implementing and applying health and safety practices at their
workplaces. Managers allocate funds, time and human resources
to implement, maintain and evaluate the operation of the GoA
OH&S Program, Goals and Plans within their business units. They
demonstrate commitment to health and safety by providing
leadership and direction to their staff in the achievement of OH&S
plans. Managers must ensure the GoA OH&S Program Standard
Processes are implemented for all elements of the program.
All levels of management must be able to explain the methods
used to evaluate their performance of assigned health and safety
responsibilities.
Points are awarded based on the percentage of positive
responses from employees interviewed. Provide examples.
I (em, m) 0-10
Element Total 95 0
Element 7.0 Program Evaluation Page 3 of 3
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Element Number Element Name Point Value Points Assessed Percentage
1.0 OH&S Management 105 0 0
A1.0 Health and Safety Committees 85 0 0
2.0 Hazard Management 295 0 0
3.0 OH&S Training 80 0 0
4.0 Inspections 90 0 0
5.0 Emergency Preparedness 138 0 0
6.0 Incident Management 85 0 0
7.0 Program Evaluation 95 0 0
973 0 0
Audit Summary Score Sheet
Grand Total
Audit Summary Score Sheet Page 1 of 1
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YES NO N/A
Examples
1.2 Available Legislation is relevant and current.
Strategically located in work areas.
Hard copy readily available to employees or readily
available on line.
A1.5 Meeting minutes are available to employees in hard
copy or online.
Examples
2.6 Randomly select several engineering controls from
hazard assessment documents and confirm their
availability through observation.
2.8 Randomly select several administrative controls
from hazard assessment documents and confirm
their availability through observation.
2.9 Randomly select personal protective equipment
from hazard assessment documents and confirm
their availability through observation.
OBSERVATION TOUR CHECKLIST
OH&S Management
Hazard Management
Observation Tour Checklist Page 1 of 3
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YES NO N/A
OBSERVATION TOUR CHECKLIST
OH&S Management2.11 Randomly select several controls from each
category and confirm through observation that
employees are using them.
Engineering Controls
•
•
•
Administrative Controls
•
•
•
Personal Protective Equipment
•
•
•
2.17 Examples of equipment or machinery that has been
removed from service. If none are readily available
inquire regarding the process.
Examples
4.4 Select a sample of corrective actions from
Inspection Checklists and confirm their
implementation through observation.
Inspections
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YES NO N/A
OBSERVATION TOUR CHECKLIST
OH&S Management Examples
5.7Selected deficiencies identified in emergency
response drill reports have been corrected.
5.8 First aid supplies and services are available
Kits meet requirements
Are fully stocked and clean.
Vehicle first aid kits are appropriate and available
Examples
6.4 Select a sample of corrective actions from reports
and confirm their implementation through
observation.
Examples
Emergency Preparedness
Incident Management
Additional Items - Random Observations
Observation Tour Checklist Page 3 of 3
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