EMS Gap Analysis QuestionnaireEMS Gap Analysis QuestionnairePlease return a hard copy of this questionnaire to __________________________________ at ___________________________________ OR Email electronic copy to ___________________________________ at ___________________________________ by 00/00/00.Name:Area:Title:Facility Name:Phone:Facility Type:Roles and Responsibilities:Conducting the EMS Gap AnalysisObjectivesThe ISO 14001 Standard is internationally recognized and used by industry and government organizations to enhance environmental and operational effectiveness, efficiency, and performance. Conducting an EMS gap analysis is a key step in developing and implementing an ISO 14001 EMS. The objectives of this step include: Assisting select Areas and facilities in determining how their environmental management system compares to the 17 elements of the ISO 14001 EMS Standard, and Improving EMS assessment tools and guidance to ensure practicality and compliance with environmental requirements and other relevant requirements.Gap Analysis BackgroundThe EMS gap analysis is a self-evaluation. A series of questions will help you compare your organizations current environmental management practices against the ISO 14001 Standard. This comparison provides a baseline assessment of your organization and helps you to identify current systems in place for managing environmental issues, including existing policies and procedures, roles and responsibilities, communication systems, training programs and others. As you conduct the analysis, you will recognize strengths and weaknesses of your organizations present environmental operations and determine the extent to which your operations conform to the ISO 14001 EMS Standard.Upon completion of the analysis, you should be able to identify which of the 17 EMS elements are already in place and which you need to develop or further refine. Conducting the gap analysis will also help familiarize you with the ISO 14001 EMS Standard and the elements critical to developing, implementing, checking, and improving the EMS on a continual basis.Gap Analysis Questionnaire Description and DirectionsThe EMS Gap Analysis Questionnaire is a tool to help you conduct an EMS gap analysis assessment on your organization. When undertaking this assessment, include people who have direct knowledge of as many environmental and operational functions as possible. This is important so that several employees gain exposure to the EMS process and also because each employee brings specific knowledge about environmental practices from his or her functional area.The questionnaire first asks for basic organizational information and background information about the respondent who will be completing the survey such as name, title, roles and responsibilities, and telephone number.The bulk of the questionnaire addresses the ISO 14001 requirements. There are 17 short sections of questions that correspond to the 17 EMS elements. The 17 sections fall under the five main EMS categories of environmental policy; planning; implementation and operations; corrective action; and management review. Each of the sections are labeled with the EMS element number so you can easily reference additional information about the 17 elements of the Standard.There are three check boxes to the right of each of the questions on the Gap Analysis Questionnaire. After you respond to each question, place an "X" or a check in the block that best describes the status of the component as it relates to your EMS. The status blocks in the gap analysis tool are represented as follows:StatusNot in placePartially in placeIn PlaceXA numerical rating measuring your organizations conformance to the ISO 14001 Standard is determined from the responses on this questionnaire. A numerical rating is given for each component response as follows:Not in place = 0 points Partially in place = 1 point In place = 2 pointsThe responses are totaled for the entire questionnaire resulting in your score. The highest score possible, 172, indicates all components of the 17 elements are In place in your EMS (85 questions/components x 2 points for each component In place = 170 points). This baseline assessment enables you to focus on continual improvement. In the electronic version of the EMS Gap Analysis Questionnaire provided with the EMS Toolkit, the second tab titled "Summary Chart", contains a bar chart to give you a visual depiction of the degree to which you conform to the ISO 14001 EMS Standard. This chart can be used in management presentations to show the progress of your EMS implementation.Hints1) List of Required Documentation and Records: The ISO 14001 EMS Standard requires physical (or electronic) evidence of certain documents and records. This includes, for example, the organization's environmental policy. There is a list at the end of this gap analysis questionnaire that highlights which items require physical (or electronic) evidence in the form of documentation or records. The list is organized by each of the 17 elements in the Standard. Elements of the ISO 14001 EMS Standard that require documentation are indicated in bold text in the gap analysis questionnaire for easy reference to the requirements of the Standard.2) List of Reference Material: The second part of the list at the end of this gap analysis questionnaire is a list of reference materials you may already possess that could help you identify your current EMS status. This list is organized by each of the 17 elements of the Standard.Question Category: Environmental PolicyEMS Element 1: Environmental Policy (ISO 14001:2004(E), Paragraph 4.2)Indicators of ConformityStatusFinding / Corrective ActionNotesNot in placePartially in placeIn place1.Has top management defined the organization's environmental policy?2.Does your procedure (process) for the environmental policy ensure that the policy is appropriate to the nature, scale and environmental impacts of its activities, products, and services that are within the defined scope of your environmental management system?3.Does your environmental policy within the defined scope of your EMS commit to continual improvement and prevention of pollution?4.Does your environmental policy within the defined scope of your EMS commit to complying with applicable environmental legal requirements and other environmental requirements?5.Does your procedure (process) for the environmental policy provide a framework for setting and reviewing environmental objectives and targets?6.Does your procedure ensure that the environmental policy is documented, implemented, and maintained?7.Does your procedure (process) for the environmental policy communicate the policy to all persons working for or on behalf of the organization?8.Does your procedure (process) for the environmental policy make the policy available to the public?Is the policy consistent with other corporate policies affecting the business?Status subtotals:000Status Total:016 points availablePercentage complete:0Question Category: PlanningEMS Element 2: Environmental Aspects (ISO 14001:2004(E), Paragraph 4.3.1)Indicators of ConformityStatusFinding / Corrective ActionNotesNot in placePartially in placeIn place9.Does your procedure (process) for environmental aspects address: Identifying environmental aspects of activities, products, and services within the defined scope of the EMS that it can control and those which it can influence taking into account planned or new developments, or new or modified activities, products and services?10.Determining those aspects that have or can have significant impact on the environment?11.Maintaining a documented up-to-date list of all aspects including those that are significant?12.Ensuring that significant environmental aspects are considered in developing, implementing and maintaining the EMS?Is there a risk assessment process to determine significance or priority of identified environmental aspects/impacts?Status subtotals:000Status Total:08 points availablePercentage complete:0EMS Element 3: Legal and Other Requirements (ISO 14001:2004(E), Paragraph 4.3.2)Indicators of ConformityStatusFinding / Corrective ActionNotesNot in placePartially in placeIn place13.Does your procedure (process) for environmental legal and other environmental requirements address: Identifying applicable legal requirements related to your organization's environmental aspects? Accessing applicable legal requirements related to your organization's environmental aspects? Determining how the legal requirements apply to your organization's aspects? Identifying other environmental requirements to which your organization subscribes? Accessing other environmental requirements to which your organization subscribes? Determining how other environmental requirements to which your organization subscribes apply to your organization's aspects?14.Does your procedure ensure that environmental legal and other environmental requirements to which the organization subscribes are considered in developing, implementing and maintaining your organization's environmental management system?Status subtotals:000Status Total:014 points availablePercentage complete:0EMS Element 4: Objectives, Targets and Programme(s) (ISO 14001:2004(E), Paragraph 4.3.3)Indicators of ConformityStatusFinding / Corrective ActionNotesDoes your procedure (process) for Objectives, Targets and Programmes address:Not in placePartially in placeIn place15.Establishing and maintaining documented environmental objectives and targets at relevant functions and levels within the organization?16.Establishing measurable objectives and targets, where practicable, that are consistent with the environmental policy, including the commitments to prevention of pollution, compliance with legal and other environmental requirements and continual improvement?17.The legal and other environmental requirements, its significant environmental aspects, its technology options and its financial, operational and business requirements and the views of interested parties when establishing and reviewing objectives and targets?18.Does your procedure (process) address establishing and maintaining programs for achieving your organization's objectives and targets, including designating responsibility for achieving objectives and targets at relevant functions and levels of your organization?19.Does your procedure (process) address establishing and maintaining programs for achieving your organization's objectives and targets, including the means and time-frame by which the objectives and targets are to be achieved?Have specific environmental improvement objectives been communicated to all relevant business units and employees, contractors and suppliers?Determine whether the facility has prepared and implemented sufficient written policies and procedures to ensure compliance with applicable standards and consistency in implementation practices, and to provide guidance on how to meet applicable standards.Confirm that the facility has established compliance standards to be followed that are reasonably capable of reducing the prospect of criminal conduct.Verify, where possible, that the facility has taken steps to achieve compliance with its environmental standards.Verify that the facility has a program in place to review the full range of capital projects, maintenance modifications, process changes, and R&D initiatives to identify potentially significant consequences.Determine if these review are performed in a timely manner, by appropriately trained professionals and if a formal methodology is employed.Status subtotals:000Status Total:010 points availablePercentage complete:0Question Category: Implementation and OperationEMS Element 5: Resources, roles, responsibility and authority (ISO 14001:2004(E), Paragraph 4.4.1)Indicators of ConformityStatusFinding / Corrective ActionNotesDoes your procedure (process) for resources, roles, responsibility and authority address:Not in placePartially in placeIn place20.Management ensuring the availability of resources (human resources & specialized skills, internal infrastructure, technology and financial resources) essential for the implementation and control of the environmental management system?21.Defining, documenting and communicating the roles, responsibilities and authorities to facilitate effective environmental management?22.Top management appointing a specific management representative who, irrespective of other responsibilities, has defined responsibilities and authority for: Ensuring that an environmental management system is established, implemented, and maintained in accordance with the requirements of ISO 14001? Reporting on the performance of the environmental management system to top management for review and as the basis for improvement?Verify if the roles and responsibilities cover: Legal/regulatory tracking; Updating/reviewing documentation control procedures; Training; Policy and procedure development; Contractor oversight; Follow-up to inspections/audits/periodic reviews; Updating the environmental policy; Identifying environmental aspects/impacts of on-site operations; and, Responding to external requests for information.Verify that the roles are clearly defined, documented, and understood and that there are no redundancies or gaps in the coverage.Interview staff from various operating departments to confirm that environmental roles and responsibilities are clearly understood within the facility.Status subtotals:000Status Total:08 points availablePercentage complete:0EMS Element 6: Competence, training and awareness (ISO 14001:2004(E), Paragraph 4.4.2)Indicators of ConformityStatusFinding / Corrective ActionNotesDoes your procedure (process) for competence, training and awareness address:Not in placePartially in placeIn place23.Identifying training needs to ensure that any person(s) performing tasks on the organization's behalf that have the potential to cause (a) significant environmental impact(s) identified by the organization is/are competent on the basis of appropriate education, training, or experience?24.Identifying training needs associated with the organization's environmental aspects and its EMS? Providing training or taking other actions to meet these needs?25.Making persons working for the organization or on its behalf aware of: The importance of conformity with the environmental policy and procedures and with the requirements of the environmental management system? The significant environmental impacts, actual or potential, of their work and the environmental benefits of improved personal performance? Their roles and responsibilities in achieving conformity with the environmental policy and procedures and with the requirements of the environmental management system, including emergency preparedness and response requirements? The potential consequences of departure from specified operating procedures?The scope of training includes: Emergency response and preparedness; The importance of complying with established performance criteria and the potential consequences of departure from specified environmental operating procedures; Adequate detail to motivate personnel to prevent, detect, and correct violations; and, The facility offers all staff an opportunity to attend internal environmental training sessions.Identify a sample of facility personnel who perform tasks that can cause significant environmental impact.Verify that these staff members have received appropriate environmental training relative to the job functions/tasks performed.Confirm that the facility promotes environmental awareness through periodic memoranda, use of bulletin boards, environmental newsletters, award programs, etc.Confirm whether staff with environmental responsibilities have the relevant background, training, and capabilities to effectively carry out their responsibilities.Status subtotals:000Status Total:012 points availablePercentage complete:0EMS Element 7: Communication (ISO 14001:2004(E), Paragraph 4.4.3)Indicators of ConformityStatusFinding / Corrective ActionNotesDoes your procedure (process) for Communication address:Not in placePartially in placeIn place26.Establishing and maintaining procedures for internal communication between the various levels and functions of your organization with regard to your organization's environmental aspects and environmental management system?27.Establishing and maintaining procedures for receiving, documenting, and responding to relevant communication from external interested parties with regard to your organization's environmental aspects and environmental management system?28.The organization's decision on whether to communicate externally on its significant environmental aspects and the documentation of that decision?If the decision is to communicate externally on its significant environmental aspects, does the organization have a method(s) for this external communication?Status subtotals:000Status Total:08 points availablePercentage complete:0EMS Element 8: Documentation (ISO 14001:2004(E), Paragraph 4.4.4)Indicators of ConformityStatusFinding / Corrective ActionNotesNot in placePartially in placeIn place29.Does your environmental management system documentation include: An environmental policy, objectives and targets for your organization?- a description of the scope of the environmental management system? A description of the main elements of the environmental management system and their interaction and reference to related documents? Documents and records required by the ISO 14001 Standard (at minimum those bolded in this gap analysis tool)? Documents and records the organization determined necessary to ensure the effective planning, operation and control of processes that relate to its significant environmental aspects?Status subtotals:000Status Total:010 points availablePercentage complete:0EMS Element 9: Control of Documents (ISO 14001:2004(E), Paragraph 4.4.5)Indicators of ConformityStatusFinding / Corrective ActionNotesNot in placePartially in placeIn place30.Does your document control procedure(s) address the need to control documents required by the environmental management system and by the International Standard?31.Does your document control procedure(s) address the need to: Approve documents before they are issued? Review and update them as necessary, and re-approve them before reissuing them? Ensure changes and the current revision status of documents are identified? Ensure current documents are available at points of use? Ensure documents are legible and easily identifiable? Ensure that external documentation you deem necessary for the planning and operation of the environmental management system are identified and their distribution controlled? Ensure obsolete documentation is not unintentionally used? Identify obsolete documentation if it needs to be retained for any purpose?Evaluate whether: There are systems in place to ensure that all required reports are sent to regulators in a timely fashion; The documentation/records system clearly identifies the maintenance retention period, and disposition of records; and, Employees have access to environmental documents they need to conduct job activities.Status subtotals:000Status Total:018 points availablePercentage complete:0EMS Element 10: Operational Control (ISO 14001:2004(E), Paragraph 4.4.6)Indicators of ConformityStatusFinding / Corrective ActionNotesDoes your procedure (process) for Operational Controls:Not in placePartially in placeIn place32.Identify those operations that are associated with the identified significant environmental aspects consistent with your organization's environmental policy, objectives and targets?33.Establish and maintain documented procedures to control situations for those operations where absence of documented procedure(s) could lead to deviation from your environmental policy, objectives and targets?34.Plan these operations in order that they are carried out under specific conditions, stipulate operating criteria, establish, implement and maintain environmental procedures related to goods and services used by the organization and communicate applicable requirements to suppliers and contractors?Status subtotals:000Status Total:06 points availablePercentage complete:0EMS Element 11: Emergency preparedness and response (ISO 14001:2004(E), Paragraph 4.4.7)Indicators of ConformityStatusFinding / Corrective ActionNotesDo you establish and maintain a procedure (process) for emergency preparedness and response that addresses how to:Not in placePartially in placeIn place35.Identify potential emergency situations and potential accidents that can have (an) impact(s) on the environment and how the organization will respond?36.Respond to actual emergency situations and accidents and prevent or mitigate associated environmental impacts?37.Does your organization periodically review and, where necessary, revise the emergency preparedness and response procedures, in particular, after the occurrence of accidents or emergency situations?38.Does your organization periodically test the emergency preparedness and response procedures where practicable?Confirm that the procedures have been updated, as appropriate, in response to new information or program reviews.Status subtotals:000Status Total:08 points availablePercentage complete:0Question Category: CheckingEMS Element 12: Monitoring and measurement (ISO 14001:2004(E), Paragraph 4.5.1)Indicators of ConformityStatusFinding / Corrective ActionNotesDo you establish and maintain a procedure (process) for monitoring and measurement that ensures:Not in placePartially in placeIn place39.Key characteristics of your operations (that can have a significant environmental impact) are monitored and measured on a regular basis?40.Information is documented to monitor performance, applicable operational controls, and conformity with the objectives and targets of your organization?41.Monitoring and measurement equipment is calibrated and maintained and all associated records are retained?Status subtotals:000Status Total:06 points availablePercentage complete:0EMS Element 13: Evaluation of compliance (ISO 14001:2004(E), Paragraph 4.5.2)Indicators of ConformityStatusFinding / Corrective ActionNotesNot in placePartially in placeIn place42.Does your procedure (process) to meet the organization's commitment to compliance ensure that you periodically evaluate compliance with applicable environmental legal requirements and other environmental requirements to which the organization subscribes?Status subtotals:000Status Total:02 points availablePercentage complete:0EMS Element 14: Nonconformity, corrective action and preventive action (ISO 14001:2004(E), Paragraph 4.5.3)Indicators of ConformityStatusFinding / Corrective ActionNotesNot in placePartially in placeIn place43.Do you establish and maintain a procedure (process) for controlling non-conformities and taking corrective and preventive actions?44.Does the procedure for controlling non-conformities and taking corrective and preventive action ensure that: Actual non-conformity(-ies) are identified and corrected and their environmental impact(s) are mitigated? Actions are taken to investigate and eliminate the causes of nonconformities so that they do not occur again? Actions are determined to eliminate the causes of potential non-conformities and to prevent their recurrence?45.Are any measures taken to identify, correct, mitigate, prevent or eliminate the nonconformity(-ies) consistent with the magnitude of the problems and the environmental impacts encountered?46.After corrective and preventive actions have been taken, are they reviewed and the program adjusted accordingly by implementing and documenting any new changes that result from the findings?Status subtotals:000Status Total:012 points availablePercentage complete:0EMS Element 15: Control of Records (ISO 14001:2004(E), Paragraph 4.5.4)Indicators of ConformityStatusFinding / Corrective ActionNotesNot in placePartially in placeIn place47.Has your organization created and maintained records as necessary that demonstrate compliance with the EMS and conformance to the requirements of the ISO 14001 Standard, including evaluation of compliance with environmental legal requirements and other environmental requirements to which the organization subscribes and the implementation of procedures and results achieved?48.Does your procedure (process) for records management describe how the records will be identified, stored, protected, retrieved, retained, and disposed?49.Are the records themselves legible, identifiable, and traceable?Status subtotals:000Status Total:06 points availablePercentage complete:0EMS Element 16: Internal audit (ISO 14001:2004(E), Paragraph 4.5.5)Indicators of ConformityStatusFinding / Corrective ActionNotesDoes your procedure (process) for an internal environmental management system audit:Not in placePartially in placeIn place50. Ensure that internal environmental management system audits are conducted at planned intervals? Determine whether the environmental management system conforms to planned arrangements for environmental management including the requirements of the ISO 14001 Standard? Determine whether the environmental management system has been properly implemented and is maintained? Determine whether the environmental management system provides information on the results of audits to management?51.Plan, establish and maintain the environmental management audit program taking into consideration the environmental importance of the operation(s) concerns and the results of previous audits?52. State the responsibilities and requirements for planning and conducting audits? State the responsibilities and requirements for reporting results? Define the audit criteria, scope, frequency and methods and explain how you have determined them?53.Ensure that the selection of auditors and the conduct of the audits maintains the objectivity and impartiality of the audit process?Status subtotals:000Status Total:018 points availablePercentage complete:0Question Category: Management ReviewEMS Element 17: Management review (ISO 14001:2004(E), Paragraph 4.6)Indicators of ConformityStatusFinding / Corrective ActionNotesDoes your procedure (process) for Management Review:Not in placePartially in placeIn place54.Ensure continuing suitability, adequacy, and effectiveness of the environmental management system through top management review of it at planned intervals?55.Ensure that opportunities are assessed for improvement and the need for changes to the environmental management system including the environmental policy and environmental objectives and targets are assessed?Ensure that the results of the management reviews are documented?56.Contain input which includes the following: results of environmental management system audits, communication from external interested parties, the performance of the environmental management system, the extent to which objectives and targets have been met, status of corrective and preventive actions, follow-up actions from previous management reviews, changing circumstances, and recommendations for improvement?57.Ensure that the outputs from the management review include any decisions and actions related to possible changes to the environmental policy, objectives and other elements of the environmental management system, consistent with the commitment to continual improvement?Confirm that a review process exists to update the policy and to communicate changes to appropriate stakeholders.Status subtotals:000Status Total:010 points availablePercentage complete:0Program TotalsElement subtotals:000Program Total:0172 points availableTotal Program percentage complete:0Required Documents and RecordsReference MaterialsElement 1: Environmental Policy- Organization's Environmental Policy- Environmental PolicyElement 2: Environmental Aspects- List of significant aspects- Results of environmental aspects identification process- List of all aspects- List of critical business functionsElement 3: Legal and Other Requirements- Laws, regulatory and other code requirements- Voluntary standard agreementsElement 4: Objectives and Targets- Environmental objectives and targets- List of performance measures for decontaminations process- List of programs associated with significant aspects- Wastewater management plan- Hazardous management plan- Chemical management plan- Process Safety management- Bloodborne pathogens program- Communications programElement 5: Resources, roles, responsibility and authority- Roles, responsibilities, and authorities for the environmental management system- Job descriptions for key on site staff for programs to address significant aspects- Budgets- Work schedules- Organizational charts- Staffing assignmentsElement 6: Competence, training and awareness- Training material and sign up sheets- Shift change meeting notes- Training records- Resumes of staff responsible for key programs- Roster of fully equipped and trained emergency personnel with the authority to perform essential functions and activitiesRequired Documents and RecordsReference MaterialsElement 7: Communication- The organization's decision whether to communicate their environmental aspects externally- Key presentations- Newsletters- Town meeting presentations- PR releases- Web based information- Communications with customers, suppliers, contractors and other external parties- Correspondence with management- Master call list for employees- Internal communication procedure- External communication procedure- Sample scriptElement 8: Documentation- Documents and records determined by the organization to be necessary to ensure the effective planning, operation and control of processes that relate to its significant environmental aspects- Description of the main elements of the EMS and their interaction and reference to related documentsElement 9: Document Control- List of key documents- Legal documents- PermitsElement 10: Operational Control- Operational Control Procedures- Procedures for different media(where the absence of documented procedures could lead to deviation from the- Contactor environmental plansenvironmental policy and the objectives and targets)- Operational controls- Sampling procedures- Preventative maintenance plan for equipmentElement 11: Emergency preparedness and response- Site emergency response plan- Incident notification procedure- Organization evacuation procedure- Employee meeting and disbursement procedureRequired Documents and RecordsReference MaterialsElement 12: Monitoring and measurement- Records associated with calibration and maintenance of monitoring and measurement equipment- Records of monitoring and measurements- Information to monitor performance, applicable operational controls and conformity with the organization's environmental objectives and targets- Reports of progress toward meeting objectives and targets- Monitoring equipment calibrations- Accident investigation reports- Injury and illness reports- Permits, licenses and other approvalsElement 13: Evaluation of legal compliance- EMS audit and regulatory compliance audit reportsElement 14: Nonconformity and preventative and corrective action- New changes to the program resulting from findings once the corrective and preventive actions have been taken- Reports of identified nonconformance, corrective action plans and corrective action tracking- Reports of hazardous material spills or other environmental incidentsElement 15: Records- Records as necessary to demonstrate conformity to the requirements of the EMS and of the International Standard.- Training, environmental management audit and management review- Sampling and monitoring data- Equipment maintenance records- Record retention policy- Vital legal and financial records (accounts receivable; contracting and acquisition files; official personnel files: social security, payroll, retirement, and insurance records; and property management and inventory records)- Logs and notes for emergency response exercisesElement 16:Internal environmental management system audit- Self assessments- Environmental management audit reportsElement 17: Management review- Results of management reviews- Senior managers meeting minutes- Change to environmental management system- Results of management review

&L&LThis is a controlled document DO NOT reproduce or distribute.&C &RDraft 2008 PPI &P&L&LThis is a controlled document DO NOT reproduce or distribute.&C &RDraft 2008 PPI &P

Summary Chart1Environmental Policy2Environmental Aspects3Legal and Other Requirements4Objectives, Targets and Programs5Resources, Roles, Responsibility and Authority6Competence, Training and Awareness7Communication8Documentation9Control of Documents10Operational Control11Emergency Preparedness and Response12Monitoring and Measurement13Evaluation of Compliance14Nonconformity, Corrective Action and Preventive Action15Control of Records16Internal Audit17Management Review

Summary Chart00000000000000000

ISO 14001:2004 EMS Elements% CompleteFacility Name and Type