COR 2020 AUDIT HANDBOOK - IHSA

COR™ 2020 Audit Handbook

COR2020HB July 2020

The Infrastructure Health & Safety Association (IHSA) is your new partner in preventing workplace injury and illness. We serve the transportation, electrical, utilities, construction, aggregates, pipelines, and ready-mix concrete industries.

IHSA was founded in January 2010 by amalgamating the Construction Safety Association of Ontario (CSAO), the Electrical & Utilities Safety Association of Ontario (E&USA) and the Transportation Health and Safety Association of Ontario (THSAO).

We are committed to providing you with world-class service and the information you need to prevent occupational injury and illness.

Disclaimer:

The contents contained in this publication are for general information only. This publication should not be regarded or relied upon as a definitive guide to government regulations or to safety practices and procedures. The contents of this publication were, to the best of our knowledge, current at the time of printing. However, no representations of any kind are made with regard to the accuracy, completeness or sufficiency of the contents. The appropriate regulations and statutes should be consulted. Readers should not act on the information contained herein without seeking specific independent legal advice on their specific circumstance. Infrastructure Health & Safety Association is pleased to answer individual requests for counseling and advice.

© Infrastructure Health & Safety Association 2010.

All rights reserved. This publication may not be reproduced, in whole or in part, or stored in any material form, without the express written permission of the copyright owner.

I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 2

COR™ 2020 Audi t Handbook

TABLE OF CONTENTS

INTRODUCTION ....................................................................................................................... 3

A. INSTRUCTIONS FOR COMPLETING COR™ 2020 .............................................................. 4

COR™ 2020 PROCESS ........................................................................................................ 5

1. Preparing for the Audit .................................................................................................... 5

General Audit Information ............................................................................................... 5

Audit Tool Format ........................................................................................................... 8

Verification Techniques .................................................................................................. 9

Scoring Legislated Requirements ..................................................................................10

Scoring ..........................................................................................................................10

Auditor’s Notes ..............................................................................................................12

2. Performing the Audit ......................................................................................................14

Document Review .........................................................................................................14

Interviews ......................................................................................................................16

Observations .................................................................................................................18

3. Summarizing the Audit ...................................................................................................19

Audit Summary Report ..................................................................................................19

Corrective Action Plan ...................................................................................................19

4. Submitting the Audit .......................................................................................................20

B. COR™ 2020 INTERNAL AUDIT EVIDENCE TIPS ...............................................................23

INTRODUCTION ..................................................................................................................23

AUDIT TIPS ..........................................................................................................................25

DEFINITIONS .......................................................................................................................50



INTRODUCTION

This document has been made available by the Infrastructure Health and Safety Association

(IHSA). It is for the use of the Ontario COR™ 2020 registered organization’s internal auditors.

Senior Management Representatives must be familiar with the content and ensure the program

requirements are met and the Internal Auditor(s) have the support and resources they need.

The COR™ 2020 Audit Handbook has two sections:

A. Instructions for completing COR™ 2020 audit requirements

The purpose of this section is to provide internal auditors with:

Instructions on how to complete internal/maintenance audits from the pre-audit stage

to post-audit stage

Information regarding methods of verification (observation, documentation,

interviews)

Information on scoring methods

B. COR™ 2020 Internal audit evidence tips

The purpose of this section is to provide internal auditors with:

Tips and assistance in completing the COR™ 2020 Audit Tool efficiently and

effectively



A. INSTRUCTIONS FOR COMPLETING COR™ 2020

Before you begin the COR™ 2020 audit process, here are a few things to consider or

verify:

All workplaces covered under your Workplace Safety & Insurance Board (WSIB)

account being considered for COR™ 2020 are included in the audit.

As the permanent full-time employee(s) assigned as Internal Auditor(s) for your

organization, you must have completed all pre-requisite training. Ensure IHSA is

informed if the internal auditor changes.

Have you reviewed the COR™ 2020 Program Guideline recently?

The COR™ 2020 Program Guideline is available on the IHSA Website at:

ihsa.ca/cor-home

Have you set aside a realistic amount of time to perform the audit?

The time to complete it will depend on the number of employees in your organization,

the scope of its work and the number of active projects or workplaces.

Have you reviewed the audit instructions to ensure you are familiar with the Audit

Tool and how to proceed?

Before applying for COR™ 2020, your organization must have a functioning occupational health

and safety management system (OHSMS) in place for at least one year and include the 14

elements required for the COR™ 2020 audit.

https://www.ihsa.ca/cor-home



COR™ 2020 PROCESS

You can access an electronic copy of the COR™ 2020 audit package by visiting www.ihsa.ca/cor-

home and clicking on the e-file submission tool. Senior management must ensure that the

designated Internal Auditor completes the Audit Tool and supporting documents and forms

within the timeframes set out in the COR™ 2020 Program Guideline. There are three stages in

the COR™ 2020 audit process:

1. Preparing for the audit

2. Performing the audit

3. Summarizing the audit

1. Preparing for the Audit

General Audit Information

The audit requires review of documentation, observation of work in progress and interviews of

representatives of management and workers.

The time taken to complete an audit depends on the size and diversity of activities and locations

within your organization. Just considering the interview stage, each one will take approximately

30 minutes. If your audit requires 10 employees to be interviewed, the total interview time is 5

hours. Depending on where your employees are located and their availability, additional time

may be needed.

Preparation for audit includes:

Pre-audit preparation: The organization through the senior management representative

and the internal auditor must create an internal audit plan. The audit plan should be

communicated to the appropriate employees so they know what to expect when the

audit is carried out and what their responsibilities are.

Opening Meeting: The organization must hold a pre-audit meeting where the audit plan

is discussed. The organization must document the meeting by keeping minutes. The

date of the opening meeting must be recorded on the Audit Information Form that will be

submitted with your audit.

Project/workplace familiarization: The internal auditor must be familiar with the

organization and the workplaces to be audited.

http://www.ihsa.ca/cor-home




Use the checklist below to help you ensure you have covered all the details for your pre-audit

steps.

COR™ 2020 Pre-Audit Checklist

1. Inform organization or participants of requirements Completed

Determine:

Name of organization key contact person

Date, time and location of the opening meeting

Date, time and location of document review (desk audit)

Names and positions of attendees for the pre-audit meeting

Locations of active worksites for the audit

Peak activity times

Organization activities on the day of the audit

Availability of H&S manual for advance review

Auditor personal protective equipment (PPE) required

Speciality PPE and training required

Additional auditor training (e.g. WHMIS, workplace specific)

Facility for interviews (quiet, comfortable, and convenient)

Availability of records/documentation for review

Workplace/site orientation requirements

Workplace/site escort requirements

Sample size and specifics for interviews

Number of management & workers available for interview



2. Gather background information Completed

Locate: Written description of organization (website, annual report)

Organizational chart

Organization health and safety statistics

Previous audit or action plan (if available)

3. Gather tools

Obtain: COR™ Audit, interview and observation documents

Current copy of applicable health and safety legislation

Appropriate PPE (for workplace observation)

Clipboard, pens, highlighters, post-it notes, measuring tape, camera, flashlight, carrying bag/knapsack

4. Familiarization tour

Arrange: A tour of the workplace/site(s) accompanied by a knowledgeable organization employee to become familiar with the work processes and workplace/site layout before the actual audit.

5. Pre-audit meeting

Address: Confidentiality and how it will be maintained

Scope of the audit (# of sites, interviewees, etc.)

Verification methods (documentation, observation, interview)

Minimum performance standards

Procedure for handling and communicating auditor concerns e.g. dangerous situations, illegal activities etc.



Audit Tool Format

The COR™ 2020 audit tool is divided into 14 elements. Below is a snapshot of a page from the

Audit Tool.

The interview questions are also provided in a separate document if the auditor prefers to use

them in this format. This is available through the e-file submission tool at ihsa.ca/cor-home.

Audit Tool Page Format

Element identification

Maximum item score allowed

To be filled in according to scoring guidelines

Audit Question

Question Auditor’s comments

Verify information using one or more of these methods:

Documentation

Interview

Observation




Verification Techniques

The COR™ 2020 Audit uses three methods to verify implementation of the OHSMS: document

review; interview; and observation.

Verification Technique

The auditor must use one or more of the specified verification techniques, "documentation", "interview'', "observation", to determine the achieved score.

If one technique is listed, only that method is required to determine the achieved score.

A filled background in this category alerts the auditor that an interview may be required to satisfy the question criteria.

Where two verification methods are listed, the auditor may be required to perform both.

If the verification techniques are connected by "and", both methods must be used, and the question criteria satisfied to achieve the maximum score.

If the verification techniques are connected by "or", the auditor selects one method and if the question criteria is satisfied, the maximum score is achieved.

The filled background reminds the auditor that an interview may be required to satisfy the question criteria.

Documentation

Observation

Interview

Documentation and

Observation

Documentation or

Observation

Documentation and

Interview

Documentation or

Interview



Scoring Legislated Requirements

All questions identified as legislated (*) must achieve a full score (100%) to pass the audit.

If you are not fully compliant with all the legislated requirements, you will need to take

action and become 100% compliant before you send in the audit for assessment. Please

acknowledge that this performance gap existed, has been corrected, and documented in

your auditor notes. This should also be documented on your corrective action plan and

submitted to IHSA.

NOTE: If the legislated requirement is not applicable (N/A), enter the full score in the score

achieved column and note the N/A, and reason for applying it, in the auditor’s notes. IHSA

will adjust the audit score to reflect the N/A if it is applicable.

Scoring

Every audit question is verified by appropriate documentation, observation and/or interview.

Every question in the audit must have a score assigned to it and it must be recorded in the

“score achieved” column.

A score of zero (0) is recorded where there is no evidence that a question has been

implemented. Full marks are assigned when there is evidence to show that the question has

been implemented and there are documents, interviews and/or observations to show this.

Partial scores can be applied to specific questions in the audit tool.

Not all audit questions may apply to an organization’s operations. When this occurs, enter

the full score in the score achieved column and note the N/A, and reason for applying it, in

the auditor’s notes. IHSA will adjust the audit score to reflect the N/A if it is applicable.

Legislated items are identified by an asterisk in the legislated column



The following examples provide detail on the “Score Possible” and partial scores:

Score Possible

Score Possible The number value represents the maximum score allowed for this Audit Question.

A clear background signifies the score is either the maximum allowed or zero (0).

A filled background signifies the maximum score, but allows for a partial score if the auditor determines that some, but not all of the item criteria have been satisfied.

A filled background with a split cell signifies that two verification techniques are used to verify the element question and that a partial score may be assigned to each technique.

3

4

3

2



Partial Scores

Partial scores are recorded when there is some evidence that a question has been implemented

but not enough to prove that the question has been fully implemented.

Range Scoring Guide

Maximum Score

Zero

Fully Compliant

Partially Compliant

Not Compliant

Minimum Scores for Passing the COR™ 2020 Audit

The scoring requirements are:

Minimum score of 80% for the overall audit

Minimum score of 65% on each element

Must obtain 100% on all items identified as legislated requirements

If, while completing the internal audit you identify a performance gap in your OHSMS that places

you below the minimum passing score required, you must take action by creating and

implementing a corrective action plan prior to sending the audit to IHSA for review.

Auditor’s Notes



The auditor is required to write comments in the auditor’s notes section. These include:

Reference to where supporting evidence is found (document page number or document title)

Brief explanation of what documents are being provided

Reference to support material (forms, minutes) that are used for verification

Detailed notes about what was observed by the auditor

Detailed descriptions of what the photograph demonstrates if it is used to validate

observations

Reason for assigning a score of zero, partial score or N/A

Any other comments or reminders which may assist the auditor

NOTE: The IHSA Auditor reviewing the audit will be using the information in the Auditor’s

Notes to navigate the audit submission. The IHSA Auditor will only consider evidence

that is referenced in the Auditor’s Notes and is accurately cross referenced to the audit

question it is validating.

Calculations

At the end of each element, there is a space for the score for the element. The Audit Tool will

automatically calculate the score.



2. Performing the Audit

Once the preparation has been done, the auditor is ready to proceed with gathering the

information required by the COR™ 2020 Audit. This involves reviewing the documentation for

the organization’s OHSMS, as well as, gathering supporting evidence by obtaining records,

interviewing employees and observing work practices.

Document Review

The documentation review and verification must be done before the interview and observation

portions of the audit.

The document review involves assessing the content and completeness of the organization’s

health and safety manual and any records and/or forms pertaining to health and safety.

The auditor is looking for evidence of organization/work specific practices and procedures.

Records and forms are examined for completeness by for example: checking for dates,

frequency, agenda items, signatures and attendance.

Three consecutive samples of evidence must be made available. See Example 2

Ensure that you have highlighted and cross referenced the specific verifying information in your

health and safety program manual and on the records and forms that are being submitted. Add

in the element and question number reference from the audit tool (Examples 1 and 2)

Example 1

SAMPLE Construct ion Company Inc. Health and Safety Manual

Issue Date: January 2002

Section 9 Page 1

Workplace Inspections Revised: January 2012 Reviewed by: M. Truwe CEO

Purpose

Inspecting the workplace to ensure that the appropriate controls are in agreement of the company health and safety

program. Inspections can help identify problems and assess risks before accidents or injuries occur.

1. Supervisors and health & safety reps will conduct documented workplace inspections.

2. The inspections will cover all company premises and job sites.

3. The INS Form is to be used as a guideline since specific sites may have unique situations and potential hazards that

may not be covered by this list.

4. Planned inspections will occur weekly on project sites and monthly at the company premises.

5. Review previous inspection records and note any commonly reported hazards.

6. Use your eyes, ears and other senses to identify actual or potential problems as you go about your inspection.

7. Record the hazards on the INS Form.

8. When unsafe conditions require immediate action, correct the situation.

9. A copy of the inspection form will be kept on the project.

Item 9.2

Item 9.2 (d)

Item 9.2 (d)

Item 9.2 (h)



Example 2

Site/Contractor Name: SAMPLE Construction Date: 25/05/20


Ref. Item 9.3


Location: No. of Workers

53 Conducted By:

S – Satisfactory NS - Not Satisfactory NA - Not Applicable

Item Inspected S NS N/A Immediate Action

1. Site Access

Clean, level around

Adequate ramps

Adequate stairs

Adequate ladders

Other

2. Housekeeping

Clear walkways

Documents required for verification may include but are not limited to:

Organizational chart

Health and Safety policy statement

Orientation records and individual training records for all employees [as required]

Hazard assessment

Organization rules, safe work practices and safe job procedures (controls)

Equipment/tool maintenance log and inspection checklists

Incident reports

Health and safety statistical reports

Completed workplace inspection reports (including completed corrective action plans)

Emergency response plans



Interviews

The purpose of the interview is to gauge employee understanding of the OHSMS.

Representatives of both management and workers will be interviewed to verify specific audit

questions. The auditor will determine whether the interviewee provides a positive or negative

response and mark the item accordingly.

Example of an Interview Question

9.4 Are pre-use inspections being performed as per the procedure?

Workers Are you required to do pre-use inspections? Please provide some examples.

# of POSITIVE

(+)

# of NEGATIVE

(-) SUBTOTAL

TOTAL (percentage)

9.10 Are the results of workplace inspections communicated to senior management as per the inspection procedure?

Management How are the results of inspections communicated to senior management?

# of POSITIVE

(+)

# of NEGATIVE

(-) SUBTOTAL

TOTAL (percentage)

Use the organizational chart to select a cross section of employees (management and

workers) to interview.

Senior management should ensure interviewees are available and understand the

purpose of the audit.

Interviews will be conducted one-on-one. Group interviews are not acceptable.

The auditor is required to ask each interviewee all questions that apply to their position

(management or worker) and mark them accordingly.

Interview Questions



Ask the questions as they are written. If it is necessary to paraphrase or probe further,

do not change the intent of the question.

Do not provide the answers or lead the respondents to the answers.

In order to achieve a maximum score for all or nothing interview questions, 51% of all

employees interviewed (combined total of management plus workers) must give a

positive response to the question. A positive response is one in which the interviewee

indicates they know about the requirements and what they and others must do.

For partial score interview questions, a minimum of 51% is required to obtain 1

point and a minimum of 75% is required to obtain the full mark.

Determine the number of interviews required by using the Audit Interview Ratio Table.

The auditor may determine that additional interviews are required based on organization

size and diversity of work e.g. organization is divided by region or type of work.

A separate Interview Questions Document is provided for the auditor’s use, if preferred.

If using this separate document, the auditor must ensure the final results (total of all

interviews) are transferred to the COR™ 2020 Audit tool.

Audit Interview Ratio Table

# of employees

# of managers/supervisors

to interview

# of

workers to interview

Total to be interviewed

1 - 10 2 5 7

11 to 25 2 6 8

26 to 50 3 7 10

51 to 100 4 9 13

101 to 200 5 14 19

Over 200 6 24 30

The organization being audited must provide a professional translator for interviews if

there are any language barriers



Observations

The purpose of conducting observations is to verify the information gathered during the

documentation review and the interviews. Specifically, the auditor is visually confirming whether

the workers are following procedures and/or whether the workplace/site conforms to the legal

and organization OHSMS requirements. For example, a health and safety policy is required to

be posted. This can be verified through observation and full marks can be granted if observed.

Enter your detailed observation notes in the auditor’s notes section of the Audit Tool.

The worksites included in the audit must be representative of the overall organization

operations. To determine the number of worksites to visit refer to the Worksite Observations

Guidelines table. In addition to these active sites the main office/shop visit must be included in

the scope of the audit.

Worksite Observations Guidelines

Active Sites Minimum Number of Sites to be Visited*

1 Site must be visited

2 Both sites must be visited

3 - 4 At least 2 sites must be visited

5 - 8 At least 3 sites must be visited

9 - 30 At least one third (1/3) of the sites must be visited

30+ Employer/auditor must contact IHSA to determine representative

sampling for worksite observation

* The main office/shop must be included in addition to these worksites.



3. Summarizing the Audit

Audit Summary Report

The Audit Summary Report must be detailed enough for the organization to address the gaps in

their OHSMS. The report should contain the following content and be presented in the post-

audit meeting:

Acknowledgement to the organization and management for their efforts and assistance

during the audit

A short description of the organization being audited including the scope of work,

number of employees, number of workplaces, interviews conducted and any other

relevant information

High level summary of the significant positive findings

Summary of the audit by element, listing existing strengths and areas for improvement.

Suggestion to management to develop, implement and follow-up on the areas for

improvement with a corrective action plan

Thanks to the organization/management for allowing you to present the audit

Corrective Action Plan

The “Corrective Action Plan” is to be completed by the organization being audited (auditee) after

the auditor has presented the complete audit results.

The Corrective Action Plan describes the steps that will be taken to address the deficiencies

identified in the audit report. It will:

● Prioritize identified deficiencies from the audit

● Identify corrective action(s)/improvements required

● Assign responsibility

● Establish implementation/completion dates



Sample Corrective Action Plan

Health and Safety Action Plan for ___________________________ Organization Inc.

Item Action and Target Date By Whom Date Completed

No H&S policy posted at head office [1.1.9]

Post current copy of H&S policy on head office safety board

Bill Kay – Safety Director

March 24, 20XX

Reviewed by: ___________________________ Signature: ____________________

Name and signature (owner/senior management)

Date: _______________________

4. Submitting the Audit

By this phase of the audit process you have determined whether you have passed the audit or if

you need to make improvements to your OHSMS.

If your total audit score is less than 80%, DO NOT

SUBMIT your audit until you have made suitable

improvements to your OHSMS.

If a total score in an individual Element is less than

65%, DO NOT SUBMIT your audit until you have made

suitable improvements to the Element.

If you have scored zero for any of the items marked as

legislated requirements, DO NOT SUBMIT your audit

until you have achieved a full score for that legislated

requirement



IF YOU SUBMIT A FAILED AUDIT IT WILL BE RETURNED

Please review the following information to ensure that your internal audit is complete before

submitting it to IHSA.

1. An electronic copy of your organization Policy and Program, highlighted and cross-

referenced, must be submitted to IHSA with your internal audit using the e-submission tool.

2. Before submitting the audit, ensure that you have made reference in the Auditor’s

Notes, to the page number in your health and safety program on which the

documentation can be verified. See Example – Auditor’s Notes page XX.

3. Ensure that you have highlighted the verifying information in your Health and Safety

Program manual and cross-referenced it to the element question. See Document

Review Example 1 page XX.

4. When you are required to include copies of supplemental documents, such as

completed inspection forms or incident report forms, ensure that you have provided

the audit question number on the top right-hand corner of the document(s) for

reference. If you are verifying frequency, attach copies with 3 consecutive dates, e.g.

three days, weeks or months in a row. See Document Review Example 2 page XX.

Three consecutive samples of evidence must be made available.

Audit Information Form

The Audit Information Form can be found in the COR 2020 Audit Tool as the first excel file. This

form must be completed in full for the audit submission to be considered for review. Should this

document not be complete, the audit will be returned.



Audit Submission Checklist

The Audit Submission Checklist is found at the bottom of the Audit Information Form. All

documents and records stated on the Audit Submission Checklist must be included with the

audit submission. Should there be any items missed from the Audit Submission Checklist, the

audit will be returned.



B. COR™ 2020 INTERNAL AUDIT EVIDENCE TIPS

INTRODUCTION

Each element in the COR™ 2020 audit is structured in a similar way with questions for

policy, procedure, implementation and document control as they apply to the specific

element.

Policy

Policy is defined as a general commitment, direction or intention and is formally stated by top

management. An effective policy statement expresses top management's commitment to the

implementation and improvement of its management system.

Each element must have a policy statement that is dated and signed by the owner/CEO.

It demonstrates management’s commitment to providing the time, budget and resources

needed to effectively implement the element.

The policy statement may be a few sentences or longer depending on the element.

Procedure

Procedure is defined as a documented, specified method to carry out an activity.

The second question in each element is about the procedure. It specifies all of the requirements

that must be included in your written procedure. Make sure you cover all of these points and can

show the auditor how you did this. A copy of the written procedure must be provided to the

auditor for review.

Implementation

Implementation questions seek to identify evidence that the element is in place and actually

working as per your written procedure. Evidence may be verified through review of

documentation, interviews of managers and workers or observations of the workplace and/or

work in progress. This evidence must demonstrate that you are carrying out the element

activities as specified in your procedure for that element.



Document Control

The last question for each element is about maintenance of documents and records related to

the procedure.

Document is defined as medium containing information related to the Occupational Health and

Safety Management System (OHSMS).

Record is defined as a document stating results achieved or providing evidence of activities

performed.

As part of the OHSMS, the organization shall establish, implement, monitor and maintain

procedures to specify which documents and records will be used and maintained.

Documentation

Documentation includes documents and records required by the COR™ 2020 Program and

determined by your organization to be necessary for the effectiveness of your OHSMS.

The creation, collection, retention and distribution of documents and records shall comply with

all applicable legal requirements, collective agreements and organizational policies, as

appropriate.

Control of Documents

At the end of each element, with the exception of Element 1, there is a question that asks if

documents and records maintained as per the procedures relevant to the element. During the

audit you will be asked to show the auditor documents and records that demonstrate that the

specific procedure has been implemented. Element 1.2 Document and Record Control includes

the requirements you will need to meet to receive a full score for this question.



AUDIT TIPS

Note: Definitions for bolded terms are included in the Definitions section.

Element 1: Health & Safety Policy and Document and Record Control Evidence Tips

1.1 Health and Safety Policy

The health and safety policy sets the direction for your OHSMS. It confirms senior management’s commitment to providing a healthy and safe work environment.

Does the organization have an OHS policy statement that:

1.1.1 Includes a commitment for senior management to set and review OHS objectives and continual improvement of the OHSMS and OHS performance?

1.1.2 Includes senior management and management’s commitment to provide a healthy and safe work environment for the prevention of injuries and illnesses?

1.1.3 Expresses a commitment to be in compliance with applicable OHS legal and other requirements?

1.1.4 Expresses a commitment to work in a spirit of consultation and co-operation with workers?

1.1.5 Refers to a program that addresses health and safety responsibilities for workplace parties?

1.1.6 Recognizes the right of workers to work in a safe, healthy work environment?

1.1.7 Is signed by the president, CEO or local senior management?

1.1.8 Is current?

1.1.9 Is visibly posted in the workplace? Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.

1.1.10 Is reviewed at least annually?

1.1.11 Is communicated and understood by employees?



1.2 Document and Record Control Evidence Tips

A document/record control procedure provides direction to track, manage, and store documents and records and assists with accuracy and due diligence.

1.2.1 Does your organization have a written procedure for documentation, document control and record control that includes:

a) Roles and responsibilities

b) Documents and records determined by your organization to be necessary for the effectiveness of the OHSMS

c) Requirement to ensure documents are approved prior to issue

d) Requirement to review, update, re-approve or withdraw documents as necessary

e) Requirement to ensure changes to, and current revision status of, documents are identified and tracked

f) Requirement to ensure relevant versions of applicable documents are readily available at the point of use

g) Requirement to identify documents of external origin that may be necessary for the planning and operation of the OHSMS

h) Requirement to prevent the unintended use of obsolete documents and identify such documents if they are retained for any purpose

i) Requirement for the identification and retention of records as necessary to demonstrate conformity to the requirements of your OHSMS

j) Requirement for protection of privacy and confidentiality, as appropriate

k) Requirement to ensure documents and records remain legible and readily identifiable

Your procedure should include all items referenced in clauses a through k. Each clause is assigned one point. Only clauses that have been highlighted and properly identified will be considered.

Cross reference your procedure to the procedure requirements a through k. To show where each item is found, highlight and number your procedure.

For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 1.2.1a.



Element 2: Hazard Assessment, Analysis and Control Evidence Tips

Hazard assessment is fundamental to your OHSMS. It is a formalized way to identify your hazards and systematically analyze the risks to determine the necessary controls.

2.1 Does your organization have a documented policy statement for hazard assessment, analysis and control that is current, signed and dated by senior management?

Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.

Cross reference the date and signature and number it 2.1.

2.2 Does your organization have a written procedure for hazard assessment, analysis and control that includes:

a) Roles and responsibilities b) Required competencies for conducting hazard

assessment, analysis and control c) Requirement for involvement of appropriate competent

workplace parties such as workers, supervisors, maintenance, engineering and suppliers in the hazard assessment process

d) Requirement to conduct hazard assessments for all operations, including routine and non-routine, and human factors where work is performed

e) Requirement for reporting actual and potential hazards f) Requirement to conduct risk assessments for identified

hazards:

● Proactively prior to commencement of tasks ● When equipment, material, substance or process is

introduced or changed ● When a change to the OHSMS may impact

workplace operations or activities g) Identification of when to review, and update hazard

assessments such as after investigations, when the phase of project changes; and must be completed at least annually

h) Requirement to identify hazards originating outside of the workplace that may impact OHS within the workplace for which the organization has control

i) Consideration of legal requirements and associated standards and guidelines

j) Consideration of design and layout of the work area, ergonomics, machinery and processes

k) Requirement to utilize a standardized risk rating system to prioritize risks before and after identifying controls

l) Requirement to develop a list of identified critical tasks and/or activities based on the risk rating system

m) Specific forms for recording hazard assessments, analysis and control?

Your procedure should include all items referenced in clauses 2.2a through m. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements a through m. To show where each item is found, highlight and number your procedure.

For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 2.2a.

Only clauses that have been highlighted and properly identified will be considered.



2.3 Are hazard assessments conducted, documented and approved for all operations including routine and non-routine operations and human factors?

2.4 Have hazard assessments been updated as per the procedure?

2.5 Are appropriate workplace parties involved in the hazard assessment process as per the procedure?

2.6 Are workplace and job specific hazards clearly identified in the hazard assessment documents?

2.7 Are risks prioritized before identifying adequate controls?

2.8 Are risks prioritized after identifying adequate controls?

2.9 Is there a list of critical tasks and/or activities that was identified using a company specific risk rating assessment?

2.10 Are documented controls referenced in the hazard assessments?

2.11 Are control measures made available and appropriate employees informed of the control strategies?’

2.12 Are documented controls implemented for identified hazards?

Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.

2.13 Are documents and records maintained as per the procedures in 1.2 Document and Record Control?

Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 2.2.



Element 3: Controls Evidence Tips

Once hazards are identified and assessed, it is necessary to develop formal controls for workplace parties to follow to ensure their safety. Following the hierarchy of controls ensures the most effective controls are in place.

3.1 Does your organization have a documented policy statement for controls that is current, signed and dated by senior management?



3.2 Does your organization have a written procedure for controls that includes:


b) Requirement for senior management to approve all controls

c) Requirement to include management and workers in the development and review of controls

d) Taking into account the hierarchy of controls

i. Elimination

ii. Substitution

iii. Engineering controls

iv. Administrative controls

v. Personal protective equipment

e) Taking into account applicable legal and other requirements such as standards, guidelines or manufacturer’s instructions

f) Specific forms for documenting controls

g) Requirement to communicate control measures to affected workplace parties

h) Requirement to make control measures readily available at the point of use as required?

Your procedure should include all items referenced in clauses 3.2a through h. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements 3.2a through h. To show where each item is found, highlight and number your procedure.





3.3 Have appropriate controls been documented and approved as per the procedure?

3.4 Do the documented controls accurately reflect the organization’s activities?


3.5 Have controls been developed following the hierarchy of controls?

3.6 Have the documented controls been communicated to affected workplace parties?

3.7 Are the controls understood by workers? Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.

3.8 Are controls made readily available at the point of use?


3.9 Are the requirements for controls followed by all workplace parties?


3.10 Do both management and workers participate in the development and review of controls?

3.11 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?




Element 4: Procurement and Contractor Management Evidence Tips

When hiring service providers they may be exposed to, or create new hazards, in your workplace. It is important to make sure these hazards are assessed and controlled.

4.1 Does your organization have a documented policy statement for procurement and contractor management that is signed and dated by senior management?



4.2 Does your organization have a written procedure for procurement and contractor management that includes:


b) Requirement for the contractor/service provider to complete a hazard assessment as per Element 2 Hazard Assessment, Analysis and Control; and Element 3 Controls

c) OHS criteria for selecting, monitoring and evaluating contractor/service providers that includes:

i. The ability and competency of the contractor to be able to assess/analyze and control hazards arising from their own work that may impact the organization’s workers

ii. The ability and competency of the contractor to be able to assess/analyze and control hazards arising from the organizations work that may impact the contractor’s workers

d) Communication with workplace parties when there are changes affecting the health and safety of the work

e) Requirement for the organization to lead the coordination of their site specific OHS requirements on multi-employer workplaces

f) Specific forms for evaluating contractors and service providers?

Your procedure should include all items referenced in clauses 4.2a through f. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements 4.2a through f. To show where each item is found, highlight and number your procedure.



4.3 Has your organization followed its OHS criteria for selecting contractors and service providers?

4.4 Has your organization monitored your contractors and service providers as per the procedure?

4.5 Has your organization evaluated the contractors and service providers as per the procedure?

4.6 Has your organization communicated with relevant workplace parties when changes have occurred?





Element 5: Company Rules Evidence Tips

Company rules establish the OHS norms within the workplace. They may have many titles such as code of conduct or golden rules.

5.1 Does your organization have a documented policy statement for company rules that is current, signed and dated by senior management?



5.2 Does your organization have a written procedure for company rules that includes:

a) Roles and responsibilities for setting, implementing and complying with company rules

b) Ensuring both standard and work location specific rules are available

c) Requirement for company rules to be written and either visibly posted or provided to each employee

d) Ensuring company and workplace specific rules are clearly explained to workers in a way that they understand them

e) Ensuring company rules are applied and enforced consistently throughout the organization

f) A progressive disciplinary procedure

Your procedure should include all items referenced in clauses 5.2a through f. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements 5.2a through f. To show where each item is found, highlight and number your procedure.



5.3 Are company rules clearly stated in writing?

5.4 Are the rules visibly posted or provided to each employee?


5.5 Do workers understand the company’s rules?

5.6 Are the company rules applied and enforced consistently throughout the company?





Element 6: Personal Protective Equipment Evidence Tips

Personal protective equipment (PPE) is a common control method for many hazards. PPE is the last resort in the hierarchy of controls. When used it is important to ensure all other possibilities for controls have been considered. PPE always requires training on fit, care and use to be effective.

6.1 Does your organization have a documented policy statement for personal protective equipment that is current, signed and dated by senior management?



6.2 Does your organization have a written procedure for personal protective equipment that includes:


b) Ensuring activities requiring PPE are documented

c) Ensuring specific criteria is used to select appropriate PPE for all activities

d) Written rules and/or guidelines for the proper fitting, care and use of PPE and ensure workers are made aware of them

e) Ensuring that appropriate PPE is provided and/or made available to workers for specific activities

f) Requirement for inspection and maintenance of PPE as per manufacturer’s and legislative requirements

g) Ensuring management, supervisors, workers, sub-contractors and suppliers of service use required PPE

h) Specific forms for inspecting personal protective equipment?





6.3 Has the organization documented the required PPE

for all activities?

6.4 Is PPE selected as per the procedure?

6.5 Are there written rules and/or guidelines for the proper fitting, care and use of PPE?

6.6 Are workers made aware of the requirements for the proper fitting, care and use of PPE?

6.7 Is adequate PPE provided and made available to workers for specific activities?


6.8 Are personnel inspecting PPE as per manufacturer’s and legislative requirements?

6.9 Do management, supervisors, workers and sub-contractors/suppliers of services use required PPE?


6.10 Are documents and records maintained as per the procedure 1.2 Document and Record Control?




Element 7: Preventative Maintenance Evidence Tips

Preventative maintenance is a formalized system to ensure that equipment, tools, vehicles and facilities are kept in safe working order.

7.1 Does your organization have a documented policy statement for preventative maintenance that is current, signed and dated by senior management?



7.2 Does your organization have a written procedure for preventative maintenance that includes:


b) An inventory of items to be maintained (whether owned, leased or rented)

c) Requirement for use of preventative maintenance schedules

d) Requirement to meet manufacturers’ preventative maintenance guidelines and legislated requirements

e) Requirement to keep records including corrective actions taken

f) Qualifications for worker(s) performing the inspection and maintenance

g) Requirement to remove overdue and/or defective tools, equipment, facilities and vehicles from service

h) Specified forms and/or software for scheduling and tracking preventative maintenance?





7.3 Is there an inventory of items to be maintained?

7.4 Are there schedules that meet manufacturer’s preventative maintenance guidelines and legislated requirements?

7.5 Is preventative maintenance being performed as planned based on schedules and preventative maintenance requirements?

7.6 Do the records include corrective action taken?

7.7 Does a competent/qualified worker perform the inspection and maintenance as per the procedure?

7.8 Have defective vehicles, tools and equipment been removed from service as per the procedure?

7.9 Have vehicles, tools and equipment that are overdue for preventive maintenance been removed from service as per the procedure?





Element 8: Training and Communication Evidence Tips

Training and communication are fundamental to ensure that workplace parties understand their roles and responsibilities to implement the OHSMS. Training aids in the development and maintenance of job specific knowledge and skills needed to work safely and efficiently. Good communication allows all workplace parties to stay current with the OHSMS and deal with any issues quickly and effectively.

8.1 Training

8.1.1 Does your organization have a documented policy statement for training that is current, signed and dated by senior management?


Cross reference the date and signature and number it 8.1.1

8.1.2 Does your organization have a written procedure for training that includes:

a) Setting roles and responsibilities for those administering and managing the training procedure

b) Identifying competencies for each task/role

c) Ensuring in-house trainers are competent

d) Determining OHS training needs by:

i. Conducting training needs analysis

ii. Reviewing legislated and other training requirements

iii. Taking into consideration different levels of responsibilities, abilities, language skills and literacy

iv. Including information on the organization’s OHSMS including purpose, roles, responsibilities and rights, importance of conformity, potential consequences for deviations or noncompliance and importance of workers’ participation within the OHSMS

e) Requirement to provide training prior to the worker performing the relevant task

f) An orientation program that:

i. Is completed prior to starting work

ii. Is provided for new and young workers, returning workers, change of role

iii. Is mandatory for all workers

g) How the training will be administered and managed

h) Evaluation of learning

i) Method for maintaining training and orientation records?

Your procedure should include all items referenced in clauses 8.1.2a through i. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements 8.1. a through i. To show where each item is found, highlight and number your procedure.





8.1.3 Does the training accommodate differing levels of responsibilities?

8.1.4 Have competencies been identified for each task/role?

8.1.5 Has the organization conducted a training needs analysis as per the procedure?

8.1.6 Have employees received training that is required by legislation?

8.1.7 Have employees received training as per the procedure?

8.1.8 Is the training provided prior to the worker performing the relevant task?

8.1.9 Is orientation mandatory for all workers?

8.1.10 Has orientation training been provided as per the procedure?

8.1.11 Is in-house training delivered by a qualified competent person as per the procedure?

8.1.12 Does the organization evaluate learning as per the procedure?

8.1.13 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?

Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 8.1.2.



8.2 Communication Evidence Tips

8.2.1 Does your organization have a documented policy statement for communication that is current, signed and dated by senior management?


Cross reference the date and signature and number it 8.2.1.

8.2.2 Does your organization have a written procedure for communication that includes:


b) Senior management holding regularly scheduled organization-wide OHS meetings with all employees that include the OHSMS and its implementation at least annually

c) Communication delivered in a manner that is understood by the receiver of the message and considers ability, language skills and literacy

d) Opportunity for input from workers

e) Receiving, documenting and responding to internal and external OHS communications

f) Tailgate or tool box talks or their equivalent

g) Specific forms for recording attendance, agendas, meeting minutes and tool box talks

h) Requirement to maintain records?

Your procedure should include all items referenced in clauses 8.2.2a through h. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements 8.2.2a through h. To show where each item is found, highlight and number your procedure.



8.2.3 Does senior management of the organization hold scheduled company-wide OHS meetings with all employees?

8.2.4 Does senior management attend/participate in organization-wide OHS meetings with all employees?

8.2.5 Does two-way communication exist during these meetings?

8.2.6 Are tailgate or tool box talks or their equivalent held as scheduled?

8.2.7 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?

Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 8.2.2.



Element 9: Workplace Inspections Evidence Tips

Workplace and pre-use inspections are a proactive method to check if controls are working, identify hazards and ensure that corrective actions are taken. There are legislated requirements for workplace and pre-use inspections. It is a good practice to involve as many workers and managers as possible in the inspection process.

9.1 Does your organization have a documented policy statement for workplace inspections that is current, signed and dated by senior management?



9.2 Does your organization have a written procedure for workplace inspections that includes:


b) Requirement to conduct and keep records for workplace inspections including identifying and preventing potential non-conformities and corrective actions

c) Requirement to conduct and keep records for pre-use inspections of vehicles, machines, tools and equipment including corrective actions

d) Inspection frequencies and who is responsible to conduct them

e) Worker participation in the inspection process

f) Requirement to meet all legislation (e.g. Regulation 1101 First Aid Requirements) and manufacturer’s requirements

g) What must be inspected

h) Specific forms for recording workplace and pre-use inspections

i) Requirement to communicate inspection results to Senior Management and other relevant workplace parties?

Your procedure should include all items referenced in clauses 9.2 a through i. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements 9.2a through i. To show where each item is found, highlight and number your procedure.



9.3 Are workplace inspections being conducted using the specific forms and checklists as per the procedure?



9.4 Are inspection frequencies being adhered to?

9.5 Are assigned personnel performing inspections as required?

9.6 Are pre-use inspections being performed as per the procedure?

9.7 Are workplace and pre-use inspections meeting all legislative and manufacturer’s requirements?

9.8 Are workers involved in the general workplace inspection process?

9.9 Are identified deficiencies corrected in a timely manner as per the procedure?

9.10 Are the results of workplace inspections communicated to senior management as per the procedure?

9.11 Are inspection reports communicated to all relevant workplace parties?





Element 10: Investigations and Reporting Evidence Tips

Investigations are a method to gather information to determine the cause(s) of an incident. Corrective and preventative actions are identified and recommendations made to prevent similar incidents. There are both internal and legal reporting requirements.

10.1 Does your organization have a documented policy statement for investigations and reporting that is current, signed and dated by senior management?



10.2 Does your organization have a written procedure for

investigations and reporting that, at minimum, meets legislated requirements and includes:

a) Roles and responsibilities for workplace parties to report incidents, including near misses, conducting investigations in a timely manner and for implementing corrective and preventive actions identified as a result of investigations

b) Requirement that training is provided in legislative and organization specific reporting requirements and investigations procedures

c) Requirement to take action to mitigate any additional consequences of the incident

d) Determination of OHS deficiencies including root causes of the incident

e) Determination and implementation of corrective and preventative actions

f) Communication of investigation results and corrective and preventative actions to interested parties

g) A process measuring the effectiveness of corrective and preventative actions

h) Specific forms for investigations

i) Methods for maintaining records of incident reporting and investigation results?

Your procedure should include all items referenced in clauses 10.2 a through i. Each clause is assigned one point.






10.3 Do records show that the incident investigation and reporting procedure is being followed?

10.4 Are all workplace parties aware of reporting procedures?

10.5 Have required personnel been trained in legislative and organization specific reporting requirements and investigation procedures?

10.6 Are appropriate personnel involved in investigations as per the incident investigation and reporting procedures?

10.7 Are opportunities for corrective and preventative actions being identified and addressed?

10.8 Are corrective and preventative actions being implemented as per the procedure?

10.9 Are corrective and preventative actions communicated to workers?

10.10 Is the organization measuring the effectiveness of the corrective and preventative actions?

10.11 Are documents and records maintained as per the procedure in 1.2 Documents and Record Control?




Element 11: Emergency Preparedness Evidence Tips

Emergency response plans must be developed for potential emergency situations that are identified through the hazard assessment process. There are legislated requirements for emergency response.

11.1 Does your organization have a documented policy statement for emergency preparedness that is current, signed and dated by senior management?



11.2 Does your organization have a written procedure for emergency preparedness that includes:


b) Identification of potential emergency situations that are linked to completed hazard assessments

c) Documented response plans including roles and responsibilities of relevant employees during emergencies

d) Input to the response plan from relevant interested parties

e) Identification of resources needed to implement the emergency response plans

f) Requirement for emergency equipment to be in place, well-marked and regularly inspected and maintained

g) Prevention or minimization of injury or occupational illness for the identified emergency situations

h) First aid requirements that includes:

i. First aid station, facilities and supplies

ii. Qualified first aiders

iii. Provision to transport injured workers to medical facility

i) An appropriate emergency communication system

j) Requirement for emergency response training appropriate for employees’ role

k) Periodic testing of the emergency response plans (e.g. drills) and the maintenance of records of testing and corrective actions

l) Periodic review of emergency procedures and response plans at least annually and revision as appropriate

m) Communication of relevant information to all involved including workers, visitors, contractors, emergency response services, government authorities and the community regarding emergency response

n) Specific forms for documenting the implementation of emergency response plans e.g. inspection of equipment and testing emergency response?

Your procedure should include all items referenced in clauses 11.2a through n. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements 11.2a through n. To show where each item is found, highlight and number your procedure.





11.3 Do documented Emergency Preparedness and Emergency Response Plans include the most appropriate responses to identified hazards and address the potential for emergency situations?


11.4 Are the emergency response plans reviewed as per the procedure?

11.5 Have emergency response resources been identified and are they available?

11.6 Do the plans include input from relevant interested parties?

11.7 Do the plans define the roles and responsibilities of relevant employees and include training in emergency procedures that is appropriate to the roles and responsibilities?

11.8 Is relevant information communicated to relevant workplace parties regarding emergency response, as per the procedure?

11.9 Is an appropriate emergency communication system in place to alert workplace parties to the emergency?


11.10 Has the plan been tested for deficiencies and corrective action taken (if necessary)?

11.11 Are the appropriate number and type of fire extinguishers at marked locations?




11.12 Are workers who are required to use fire extinguishers trained how to use them?

11.13 Are fire extinguishers regularly inspected and maintained as per manufacturer and legislative requirements?


11.14 Are required first aid stations, facilities and supplies available?


11.15 Are qualified first aiders available on every shift?

11.16 Periodic inspection of first aid facilities and equipment?


11.17 Is all other emergency response equipment regularly inspected and maintained?

11.18 Is there provision for transporting an injured worker to a hospital or medical facility?






Element 12: Statistics & Records Evidence Tips

Statistics and records must be collected and reviewed to get a clear picture of your organization’s OHS performance. This information helps identify gaps and trends in your OHSMS. This can be done weekly, monthly, quarterly or annually.

12.1 Does your organization have a documented policy statement for statistics and records that is current, signed and dated by senior management?



12.2 Does your organization have a written procedure for statistics and records that includes:


b) Requirement to measure OHS performance at a specified frequency, at minimum annually

c) Qualitative and quantitative measurements appropriate to the organization

d) Leading and lagging performance indicators

e) Comparison of current health and safety performance with past performance

f) Analysis of statistics and identification of trends

g) Analysis of first aid treatment records

h) Results recorded and communicated to relevant workplace parties

i) Specified forms and/or software as needed?

Your procedure should include all items referenced in clauses 12.2a through i. Each clause is assigned one point.




12.3 Are health and safety summaries developed and maintained?

12.4 Is OHS performance being measured at a specified frequency as per the procedure?

12.5 Does the organization compare their health and safety performance with past performance?

12.6 Are the statistics analyzed and needs or trends identified?

12.7 Are first aid treatment records analyzed?

12.8 Have results been communicated to relevant workplace parties as per the procedure?





Element 13 Legislation and Other Requirements Evidence Tips

Your organization must identify all applicable OHS legislation and ensure compliance in the workplace. There are other requirements such as standards, codes, guidelines and manufacturer’s specifications that must be considered.

13.1 Does your organization have a documented policy statement for legislation and other requirements that is current, signed and dated by senior management?



13.2 Does your organization have a written procedure for legislation and other requirements that includes:


b) Identification of applicable legislation, regulations, standards and any other requirements

c) Methods to ensure compliance with applicable legislation

d) All documentation related to legislation, regulations, standards and any other requirements are up to date

e) Visible posting or availability of relevant legislation at each workplace as required

f) Evaluation of compliance to legislation at regularly planned intervals and retention of records of evaluations

g) Specific forms as required?

Your procedure should include all items referenced in clauses 13.2a through g. Each clause is assigned one point.

Cross reference your procedure to the procedure requirements 13.2a through g. To show where each item is found, highlight and number your procedure.



13.3 Has the organization identified legislation, regulations, standards and any other requirements that apply to them?

13.4 Is all required documentation current?

13.5 Has the organization evaluated their compliance to current applicable legislation as per the procedure?


13.6 Are copies of relevant legislation readily available and/or posted when required at each workplace?


13.7 Are legislated posting requirements being met?





Element 14: Management Review and Management of Change Evidence Tips

14.1 Management Review

Senior management must review the effectiveness of the OHSMS at regularly planned intervals, and at

least annually. The review will help senior management identify OHS objectives and aid in the

development of action plans for continual improvement of the OHSMS.

14.1.1 Does your organization have a documented policy

statement for senior management review that is current,

signed and dated by senior management?

Only element specific policy

statements will be considered.

It should be a distinct statement

focusing on senior management

commitment for this element.

Cross reference the date and

signature and number it 14.1.1.

14.1.2 Does your organization have a written procedure for

management review that includes:


b) The following inputs to the senior management

review:

i. Evaluation of the effectiveness of all elements

of the OHSMS

ii. Status of actions from previous management

reviews

iii. Results of internal audits, including COR™

audits

iv. Evaluations of compliance with legal

requirements

v. Results of participation and consultation with

employees/Health and Safety Representative

/Joint Health and Safety Committee

vi. Communication from external parties

vii. OHS performance of the organization

viii. Evaluation of the extent to which OHS

objectives have been met

ix. Status of incident investigations, trends

identified, implementation of corrective

actions, implementation of preventative

actions and status of actions taken

x. Changing circumstances related to OHS such

as developments in legal requirements or

technology

xi. Identified barriers to worker participation in the

OHSMS\

xii. Recommendations for improvement

Your procedure should include all

items referenced in clauses 14.1.2

a through e. Each clause is

assigned one point.

Cross reference your procedure to

the procedure requirements

14.1.2a through e. To show where

each item is found, highlight and

number your procedure.

For example, the section of your

procedure that has roles and

responsibilities would be

highlighted and numbered 14.1.2a.

Only clauses that have been

highlighted and properly identified

will be considered.



c) The following outputs to the management review:

i. OHS policy updates

ii. Measurable OHS objectives

iii. Action plan to achieve objectives

iv. Required resources

v. Revisions to any other elements of the

OHSMS as appropriate

vi. Removed barriers to worker participation in the

OHSMS

vii. Communication of the objectives and action

plan(s) to all employees

d) Specified forms for recording Management

Review

e) Method for maintaining records?

14.1.3 Does the review include all inputs as per the procedure?

14.1.4 Have measurable OHS objectives been identified as a

result of the review as per the procedure?

14.1.5 Have OHS policies been reviewed and updated?

14.1.6 Has an action plan been developed and resources

identified to meet the objectives as per the procedure?

14.1.7 Have the OHS objectives and action plan(s) been

communicated to all employees as per the procedure?

14.1.8 Are documents and records maintained as per the

procedure in 1.2 Document and Record Control?

Provide 3 samples of evidence as

per the forms required in your

procedures. See 1.2 and 14.1.2.



14.2 Management of Change Evidence Tips

Management of change is a process to ensure that when changes occur hazards are assessed and

addressed. Some examples of changes are new legislation, new products, and different work processes.

14.2.1 Does your organization have a documented policy

statement for management of change that is current,

signed and dated by senior management?

Only element specific policy

statements will be considered.

It should be a distinct statement

focusing on senior management

commitment for this element.

Cross reference the date and

signature and number it 14.2.1.

14.2.2 Does your organization have a written procedure for

management of change that includes:


b) Identification of when the management of

change procedure will be implemented which

includes at a minimum:

i. Changes in legal requirements

ii. Significant changes in work processes,

control measures, equipment, organization,

work location

iii. Introduction of new products, processes or

services

iv. Introduction of new developments in OHS

knowledge or technology

c) Requirement to apply Element 2 Hazard

Assessment, Analysis and Control and Element

3 Controls to any identified changes

d) Provision of information and training for relevant

workplace parties where appropriate?

Your procedure should include all

items referenced in clauses 14.2.2a

through d. Each clause is assigned

one point.

Cross reference your procedure to the

procedure requirements 14.2.2a

through d. To show where each item is

found, highlight and number your

procedure.

For example, the section of your

procedure that has roles and

responsibilities would be highlighted

and numbered 14.2.2a.

Only clauses that have been

highlighted and properly identified will

be considered.

14.2.3 Has a hazard assessment been done as a result of

changes identified as per the procedure?

See 2.3

14.2.4 Has the organization developed relevant controls as a

result of the hazard assessment?

See 2.10. 2.11

14.2.5 Have the controls been communicated and training

provided to relevant workplace parties?

See 2.12

14.2.6 Are documents and records maintained as per the

procedure in 1.2 Document and Record Control?

Provide 3 samples of evidence as per

the forms required in your procedures.

See 1.2 and 14.2.2.

If you have any questions or concerns when completing the audit, contact IHSA.



DEFINITIONS

Action Plan: A plan that identifies the tasks to be accomplished, assigns responsibilities for

completing each task, identifies the timeline in which it is to be completed, and records the

actual action taken and completion dates.

Audit: Systematic, independent and documented process for obtaining evidence and evaluating

it objectively to determine the extent to which pre-determined criteria are fulfilled.

Audit Program: A set of one or more audits planned for a specific time frame and directed

towards a specific purpose.

Competency: A person performing a task for, or on behalf of, the organization is competent to

do so by means of appropriate:

a) Knowledge of the hazards and risks associated with the tasks for the operations and

activities

b) Demonstrated understanding and working knowledge of the control measures

associated with the hazards and risks

c) Training with regard to the hazards, risks and associated control measures

d) Aptitudes, such as skillset, ability and willingness to deal with the hazards, risks and

control measures

Compliance: Meeting all requirements outlined within applicable legislation and regulations.

Conformity: Fulfillment of a requirement.

Consultation: Process by which the organization seeks the views of the workers, worker

representatives, and workplace parties before it makes a decision.

Continual Improvement: Recurring activity to enhance performance and achieve a

measurable result.

Contractor: Person or organization providing services to another organization in accordance

with agreed upon specification, terms and conditions.



Corrective Action: Action to eliminate the cause of a non-conformity and to prevent

recurrence. There can be more than one cause for a non-conformity.

Document: Medium containing information related to the OHSMS.

Hazard: Source, situation or act with a potential for harm in terms of human injury.

Hazard Assessment: The process of conducting a systematic review to:

Identify hazards associated with work activities

Analyze or evaluate the risks(s) associated with the hazards

Determine appropriate ways to eliminate or control the hazards

This can be broken down into 3 levels:

1. Formal Hazard Assessment: A documented overall hazard assessment encompassing

all of the organizations potential hazards/ risks.

2. Site Specific Hazard Assessments: A documented hazard assessment identifying any

hazards specific to the work sites.

3. Field Level Hazard Assessment: a documented hazard assessment, which can identify

the specific conditions present where the work is being performed.

Human Factors: Is concerned with fitting the job or task to the physical and mental capabilities

of the worker. Also commonly called ergonomics.

Incident: Work related event(s) in which an injury, fatality or occupational illness occurred; and

includes event(s) where no injury or illness occurred, such as a near hit or property damage.

Interested Parties: Persons or groups, inside or outside the workplace, concerned with or

affected by OHS performance of an organization.

Legal Requirements: All applicable legislation, including but not limited to the Occupational

Health and Safety Act and its regulations.

Management: People who have care and control over people and/or processes.



Non-conformity: Non-fulfillment of a requirement.

Objective: Result to be achieved. An objective can be expressed in many ways, e.g. as an

intended outcome, a purpose, an operational criterion, as an OHS objective or by the use of

other words with similar meaning (e.g. aim, goal, or target).

Occupational Health and Safety (OHS): Conditions and factors that affect, or could affect the

health and safety of employees or other workers, inclusive of temporary workers and contractor

personnel, visitors, suppliers, vendors, or any other person in the workplace.

Occupational Health and Safety Management System (OHSMS): As defined in the OHSA

“means a coordinated system of procedures, processes and other measures that is designed to

be implemented by employers in order to promote continuous improvement in occupational

health and safety.

OHS Objective: OHS goal, in terms of OHS performance, that an organization sets itself to

achieve.

OHS Performance: Measureable results of an organization’s management of its OHS risks.

OHS Policy: Overall intentions and direction of an organization related to its OHS performance

as formally expressed by senior management in relation to the implementation of the OHSMS.

Organization: Company, corporation, firm, enterprise, authority or institution, or part or

combination thereof, whether incorporated or not, public or private, that has its own functions,

management and administration.

Other Requirements: Requirements or provisions the organization subscribes, however are

not legally binding, such as industry standards.

Participation: Involvement of workers, or worker representatives, in decision-making

process(es) regarding the OHSMS.

Plan: Detailed method for doing or achieving something.



Policy: A policy is a general commitment, direction or intention and is formally stated by top

management. A quality policy statement should express top management's commitment to the

implementation and improvement of its management system.

Preventative Action: Action to eliminate the cause of potential non-conformity or other

potential undesirable potential situation. There can be more than one cause for a potential

nonconformity. (For the purposes of this Standard, this refers to any action taken to fix a

potential OHS problem.)

Procedure: A documented, specified method to carry out an activity.

Process: A set of interrelated or interacting activities that transforms inputs into outputs.

Qualitative: Relating to the nature or description of something, rather than to its quantity.

Quantitative: The measurement or number of something rather than its quality.

Record: Document stating results achieved or providing evidence of activities performed.

Residual Risk: Combination of the likelihood of the occurrence after the hierarchy of controls

has been implemented for an identified hazard.

Risk: Combination of the likelihood of an occurrence of a hazardous event or exposure(s) and

the severity of injury or occupation illness that can be caused by the event or exposure(s).

Risk Assessment: Process of evaluating the risk(s) arising from a hazard(s), taking into

account the adequacy of any existing controls, and deciding whether or not the risk(s) is

acceptable.

Senior Management: Person(s) at the highest level of an organization’s structure responsible

for leading, managing and /or directing an organization’s day-to-day activities and/or operations.

Workplace Parties: Includes, but is not limited to, the employer, supervisor(s), workers,

constructor, visitors and owner.

Find out what we can do for you at www.ihsa.ca

Infrastructure Health & Safety Association (IHSA)21 Voyager Court South

Etobicoke, Ontario M9W 5M7 CanadaTel: 1-800-263-5024 • Fax: 905-625-8998

www.ihsa.ca

About IHSA IHSA’s vision is the elimination of all workplace injuries, illnesses, and fatalities within our member firms.

We engage with our member firms, workers, and other stakeholders to help them continuously improve their health and safety performance. We do this by providing effective and innovative sector-specific programs, products, and services.

We offer • Training programs • Consulting services • Health and safety audits • Publications and e-news • Posters and stickers • Reference material • A resource-rich website.

COR 2020 AUDIT HANDBOOK - IHSA

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