Audit Report Template 03
Audit Report Template 03
Audit Report Template 03
UQ Internal OHS
Audit Program
OHS Management Systems Audit Report
< audited location >
Contents
Introduction..............................................................................................................................................................................................2
Audit Scope...............................................................................................................................................................................................2
Audit Criteria.............................................................................................................................................................................................2
Executive Summary.................................................................................................................................................................................3
Positive Findings..................................................................................................................................................................................3
Opportunities for Improvement........................................................................................................................................................3
Audit Score................................................................................................................................................................................................4
Detailed Audit Findings & Recommendations.....................................................................................................................................5
3.1 Structure and responsibility – Resources..................................................................................................................................6
3.2 Structure and responsibility – Responsibility and accountability .........................................................................................7
3.3 Structure and responsibility –Training and competency ........................................................................................................9
3.4 Consultation, communication and reporting – Consultation ..............................................................................................12
3.5 Consultation, communication and reporting – Communication.........................................................................................13
3.6 Consultation, communication and reporting – Reporting...................................................................................................15
3.7 Documentation...........................................................................................................................................................................18
3.8 Document and data control......................................................................................................................................................19
3.9 Health and safety risk management program........................................................................................................................20
3.10 Hazard identification, risk assessment and control of risks ...............................................................................................23
3.11 Emergency preparedness and response...............................................................................................................................34
Appendix 1 Supervisors / Managers Questionnaire Results...........................................................................................................39
Appendix 2 Workers Questionnaire Results......................................................................................................................................41
Appendix 3 Walk--through Inspection Findings................................................................................................................................43
Appendix 4 Walk--through Inspection Images..................................................................................................................................45
Appendix 5 Audit Tool Scoring and Conformance Rating Definitions ...........................................................................................47
Introduction
An internal OHS audit of <area audited> was undertaken as part of the University’s internal audit program. This report
presents the findings of the site visit and audit, and provides recommended corrective actions to the audited area.
The University has a comprehensive set of OHS Policies, Procedures and Guidelines that form the OHS Management
System (refer http://www.uq.edu.au/ohs/). The audit program is designed to assist local areas to evaluate the
implementation and effectiveness of the UQ OHS Management System in their area, and to identify system deficiencies
and opportunities for improvement. A primary objective of OHS auditing is continual improvement of OHS systems to
ensure the University continues to provide a safe and healthy environment for staff, students, volunteers, contractors and
visitors.
The auditors would like to acknowledge and thank the staff < and students? > of < audited location > for their full
cooperation and positive involvement in the internal OHS Audit. We would also like to thank < local contact / WHSC > for
assisting with arranging the audit schedule and facilitating the walk--through inspections.
Audit Scope
Audit Location:
Audit Date: Report Date:
Head of Section: Email:
Audit Criteria
The internal OHS audit program has been developed using a sub--set of criteria from within Element 3 (Implementation)
of the National Self--Insurer OHS Audit Tool (NAT) and the associated OHS Goals for the University. The following
documents, databases and reporting software were referred to during the audit,
Executive Summary
The < audited location > achieved an average audit score of XX%. It has been determined that an overall score of 70% or
greater is required to demonstrate effective implementation of the University’s health and safety systems. The auditors
conclude that the health and safety systems of the < audited location > are < ?? >, and that by focusing efforts on the key
areas of non--compliance, a score greater than 70% could be achieved without difficulty …. < well developed,
supported, monitored and undergo regular review to ensure ongoing effectiveness. >
Positive Findings
< a couple of key findings / points >
Audit Score
As a self--insured organisation for workers compensation, the University is required to demonstrate adequate systems for
the management of OHS. It has been determined that a score of 70% or greater is required to demonstrate effective
implementation of the University’s Health and Safety Management Systems locally. The < area audited > achieved an
average score of XX% for the 11 criteria investigated during the audit.
3.1 •
3.2 •
3.3 •
3.4 •
3.5 •
3.6 •
3.7 •
3.8 •
3.9 •
3.10 •
3.11 •
in 2017).
and safety management system as identified • comment on the area’s specific access to OHS
through a documented review. personnel and whether these personnel are
suitably qualified and competent.
• Are these resources reviewed?
• Perhaps a comment on the availability of first aid
trained staff and building/emergency wardens.
Audit Score
safety and can demonstrate how they fulfil management OHS responsibilities.
them. • Comment on whether the senior manager can
outline OHS legal obligations, UQ OHS risk
management system, operational OHS risks,
incident response and corrective actions, and
UQ OHS responsibilities.
• Comment on any evidence of reporting of
OHS matters from Faculty, Institute staff to
the Senior Manager? (e.g. monthly OHS
report)
responsibility for the health and safety performance to the OHS Division annually.
management system and reports to that group • Is there evidence of OHS Committee matters
on its performance. and OHS goal performance being reported to
the OHS Division?
• Does the Faculty/Institute/Centre annual
report include OHS?
• Does senior manager’s PD include high level
OHS responsibilities?
act and reporting relationships in the • Is there evidence of communication to staff about
organisation have been defined, documented OHS responsibilities such as completion and
and communicated. approval of risk assessments, completion of OHS
training, OHS inspections.
• Are OHS responsibilities referenced in position
descriptions and are they communicated to staff?
Audit Score
competent persons with appropriate persons and includes interactive activities to apply the
knowledge, skills and experience. knowledge to practical examples.
• Is local training provided by competent staff?
Examples?
• Are suitably accredited and competent external
training providers accessed as required?
appropriate to their role and responsibilities • Managers complete mandatory OHS training?
within the organisation, and the relevant health o OHS for Senior Managers =
and safety legislation. o OHS for Supervisors and Managers =
• Any other examples of development of managers
within the local area – training, information
provision, briefings etc.
representatives on consultative committee(s), Training is provided for HSRs and is a half day training
receive appropriate training to enable them to course (provided a number of times during the year).
undertake their representative roles effectively. HSRs also have the legislative entitlement to
undertake formal, accredited HSR training.
• WHSC has completed training?
• HSR has completed training?
needs) is provided to all workers to enable two years. Statistics available in UQ Reportal data and
them to perform their tasks safely. some refresher training compliance results are
reported to senior management regularly.
• Comment on local “refresher” training: e.g.
% compliance with annual fire safety training, general
workplace training, First Aid Officer refresher training,
Building and Fire Warden refresher training?etc.
Audit Score
Those who represent workers on health and • Comment if the HSR is a member of OHS
safety matters: Committee or if they communicate with
a) are provided time and resources to management about OHS issues.
effectively undertake this role • Are resources provided for HSR to address OHS
3.4.3
b) meet regularly with management about issues eg time to investigate incident, funding to
health and safety issues and the minutes rectify OHS issues.
of their meetings are available to all
workers.
of procedures for the identification of hazards • Comment on whether staff or the HSR develop,
and the assessment and control of risks. implement and review hazard control and risk
management.
• State if workers or HSR’s involved in incident
investigations and corrective action development.
Audit Score
are communicated to all workers, and consider • Comment on workers’ knowledge of OHS Policy
language and standards of literacy. and other OHS information and check if workers
with non--English speaking background can
understand OHS information provided to them.
Comment on how OHS information is
communicated to workers.
workers about the progress towards the • Comment on emails, Minutes, Safety Notices,
resolution of health and safety disputes. meetings and discussions about resolution of OHS
disputes.
• Comment about awareness of formal mechanisms
for dispute resolution communication, and
provide examples of communications to workers.
Audit Score
occurrences and system failures, are reported incident reports and oversees auditing of incident
and recorded in accordance with relevant reports as one assurance that appropriate corrective
procedures. actions have been implemented.
• comment on the work area’s use of UQSafe--
Incident, including the approval rate of action
plans.
• Consider whether incidents and hazards are both
reported.
corrective action, are produced and forwarded to the relevant OHS Committee is a measure of the
to senior management and worker UQ 2015--2017 OHS Goals as is monitored by the
representative(s) as appropriate. OHS Division.
and safety objectives, targets and management Committee and Senate Risk Committee. Reports also
plans are produced and distributed within the include outcomes of local area audits, the progress
organisation. toward implementing audit recommendations,
contentious issues and incidents etc.
• Does the local area measure its OHS
performance? Comment on how, to whom, and
whether the performance measures correspond
to the corporate measures.]
• OHS Goals Review Report completed annually and
submitted to OHS Division?
safety management system are produced and Health and Safety management system reports from
distributed within the organisation. regulatory bodies (eg ESO, WHSQ, Queensland Health,
Radiation Health) are distributed to relevant senior
managers and reported to OHS Division.
equivalent document includes information responsibility. The report may include implementation
about health and safety performance. of local OHS management plans andperformance with
respect to UQ OHS Goals.
• comment on any local OHS performance reporting
that is in place
Audit Score
3.7 Documentation
The organisation’s health and safety policy, related information is located on the OHS Division
plans and procedures are documented in a website.
planned and organised manner.
Comment about:
• any local repository (eg shared drive, website, lab.
folders) where OHS information is organized. Does
it reference UQ OHS Policy and procedures, online
training modules, local risk assessments, SOPs,
competency to operate, training registers.
Audit Score
Documents and data are regularly reviewed by effectiveness, changed environment/legislation and
competent persons to ensure their current practice.
effectiveness, suitability and the currency of the Comment about:
information.
• Review of locally created documents by competent
persons and whether effectiveness, suitability and
currency of information is included in review.
Audit Score
hazards, risk assessments and risk control plans. Incident, documents action plans to manage the risks
that caused the reported incidents. These action
plans are approved by supervisors and monitored by
local OHS personnel.
• comment on local examples where hazards, risk
assessments and risk control plans have been
documented.
• Identify where risk assessments are not in place.
• Have action plans in UQSafe--Incident been
approved in the required time frame?
prioritise the implementation of risk control controls for the risks in their areas.
measures. • comment on any examples where the assessed risk
level has been used to prioritise the implementation
of risk control measures – through interviews with
staff, OHS committee minutes.
revised where necessary to ensure relevance, audit process is in place to monitor the
adequacy and compliance with health and implementation of the UQ risk management system.
safety management system requirements. • Comment about the risk assessment approval
rate (100% active risk assessments to be
approved by supervisor) and the formal review
rate (at least 95% of active risk assessments with
a “current” risk rating of “high” or “extreme” are
formally reviewed by a WHSC/OHS manager; and
at least 20% of all active risk assessments are
formally reviewed by a WHSC/OHS manager).
and managing change that may impact on committee agendas includes an item on OHS issues
health and safety. around workplace change.
• comment about any recent, current or planned
change to the workplace that demonstrates
consideration to OHS impact on staff and students.
Refer to interviews, committee minutes etc.
Audit Score
requirements is assessed in the selection of where applicable, providing all required documents
contractors and labour hire employees. e.g. Safe Work Method Statements.
Comment on:
• Contractors are engaged by P&F?
• If local area engages contractors directly can they
provide a written procedure similar to the P&F
contractor engagement process that includes
addressing OHS requirements?
handling, transfer, inventory management and chemical transport within and between UQ campuses.
transport of hazardous chemicals. Chemical inventories are maintained on Chemwatch
through staff specific log ins.
Comment on:
• Relevant training completed and up to date?
• Risk assessments approved and reviewed?
• Chemwatch inventory regularly updated and
access disseminated as appropriate?
includes (but is not limited to) relevant details • Plant/Equipment Register includes maintenance
of inspections, maintenance, repair and schedule?
alteration of plant. • Servicing/maintenance performed as per
manufactures recommendations?
• Evidence of competency for those modifying,
repairing, maintaining plant?
• Records maintained/available for each piece of
plant/equipment?
• Responsible party has been identified?
Comment on:
equipment is safe before being returned to
• Following maintenance all guarding replaced
service after repair or alteration.
prior to start--up of plant?
• Are workers notified when plant/equipment is
safe to return to use?
• How do workers verify plant/equipment is safe
to return to use?
• Records/verification of re--commissioning kept?
• 2.40 Biosafety
relevant standards and codes of practice, and
• 2.60 Occupational Health
are displayed in accordance with legal and
• 2.70 Occupational Hygiene and Chemical Safety
organisational requirements.
2.80 Radiation Safety Comment on:
• Review signage in the work area. Is it relevant
and current?
• Is signage readily visible, in good condition and in
good working order?
• Are staff adhering to signage requirements (PPE
being worn)?
are transported, handled and stored in a safe should be regularly inspected (access, stability, safe
manner. working load/height, condition etc).
Comment on:
• Annual workplace inspections completed?
• Plant/equipment registers available?
• Documented procedures outlining required
maintenance/servicing?
• Training/licensing requirements assessed and
documented? Procedure for ensuring new staff
undergo required training?
• Transport and lifting vehicles/equipment in good
working order and appropriate for task?
Comment on:
they are undertaking, to ensure that tasks are
• Is a training plan based on the UQ Training Needs
performed safely and work instructions and
Analysis (TNA) checklist completed and regularly
procedures are followed.
reviewed?
• Are competency training assessments conducted
before work tasks to verify workers understanding
of training? If yes, are records kept and can
evidence be provided?
manage the safety of itsworkers when working controlled workplace location and the work that they
at workplaces not under the control of the are performing. OHS risks associated with the work
organisation. off--campus must be documented and recorded.
Comment on:
• Risk assessment and/or work off--campus
(WOC) plans developed for all work occurring at
a non UQ controlled location?
• Established review and approval procedure for
all field work/work off--campus?
• Emergency contact details and planning in place
prior to departing?
systems are identified and clearly labelled to pipework clearly identified as per
avoid inadvertent or inappropriate use. https://www.worksafe.qld.gov.au/injury--
prevention--safety/hazardous--
chemicals/managing--hazchem--risks/storage--
and-- handling--systems
• All GMO’s labeled in accordance with 2.40.07
Requirements for the Identification of
Genetically Modified Organisms in Storage?
• All vehicles used for transport of materials
appropriately signed/labelled?
Audit Score
emergency plan appropriate to their allocated (UQ, non--UQ) are a regulatory compliance
emergency response responsibilities. requirement; the drill debriefs conducted by Deputy
Emergency Coordinator with Wardens are an
important training tool.
Comment about:
• Percentage of AFS training completion by all
workers.
• Training participation by local Building/Floor
Wardens and Deputies, and laboratory workers.
• Records of emergency tests or evacuation drills
and debrief meetings.
Competent persons have periodically assessed UQ reviews its emergency evacuation diagrams when
the suitability, location and accessibility of a change to layout occurs or at three yearly review
emergency equipment, including where date.
changes to layout, equipment or process have
occurred.
3.1 1.4
emergency authorities are informed of relevant location, types and quantities of hazardous chemicals.
hazards on--site (including hazardous chemicals)
when attending an emergency. Comment about:
• Chemical Inventory being completed and up--to--
date in Chemwatch for all relevant locations
Audit Score
Criteria / Questions S1 S2 S3 S4
Have you attended the OHS for Managers and Supervisors training, offered
3.3.8
via the UQ Staff Development program?
Are you (or the workers you supervise) required to undertake any OHS
3.3.10
refresher training? Examples?
3.5.1
Is relevant OHS information easily accessible? Where?
Is health and safety information effectively communicated within your work
3.5.1
unit? By who?
3.6.1
How would workers report an OHS issue in your work unit?
Are you able to explain your responsibilities and the actions required
3.6.1 following the injury of a worker (staff/student) supervised by you?
Criteria / Questions S1 S2 S3 S4
3.9.5
What are the top 3hazards associated with your work / research tasks?
Is there a process, procedure or guideline to ensure OHS is effectively
3.10.5
considered prior to the purchase of new chemicals/goods/equipment?
3.10.15
Is suitable training in the use of PPE provided?
3.10.15
Is PPE maintained in good working condition? Responsibilities?
Is the form “PF306 Hazards in Laboratories” completed prior to engaging
3.10.18
P&F/contractors to service/repair laboratory facilities/equipment?
3.11.2
Do you know who to call in an emergency? Phone number?
Do you know your emergency meeting point in the event of abuilding
3.11.3
evacuation?
3.11.8
Explain your understanding of the UQ Wellness program?
3.11.8
Explain your understanding of the Employee Assistance Program?
S2 Comments:
Recommendations:
S3 Comments:
Recommendations:
S4 Comments:
Recommendations:
Criteria / Questions W1 W2 W3 W4
3.3.5
Have you attended a site specific local OHS Induction? When? Who with?
3.3.5
Do you know who your WHSC is?
3.3.5
Do you know who your HSR is?
Do you know who your First Aid Officer is and/or how to obtain first aid or
3.3.5
medical assistance?
3.3.5
Do you know who your Floor Warden is?
3.3.10
Are you required to undertake any OHS refresher training? What?
Do you receive copies of the minutes from your local OHS Committee?
3.4.3
Who from?
3.4.4
Are you consulted on matters that may affect your health and safety?
3.5.1
Do you receive information about health and safety? From who?
3.6.1
How would you report a workplace incident or injury? Example?
3.9.2 Are you required to complete risk assessments for your work?
Criteria / Questions W1 W2 W3 W4
3.9.3
Has your supervisor reviewed and approved your risk assessments?
3.9.5
What are the top 3 hazards associated with your work /research tasks?
3.10.09
What are the disposal requirements for hazardous chemicals?
3.10.09
Where is chemical waste stored prior to collection?
3.10.12
How do you access safety information for hazardous chemicals?
3.10.13
What are the safety requirements for storage of hazardous chemicals?
3.10.15
Is suitable training in the use of PPE provided?
3.10.15
Is PPE maintained in good working condition? Responsibilities?
3.10.22
What are the procedures for working alone orout--of--hours?
3.11.2
Do you know who to call in an emergency? Phone number?
Do you know your emergency meeting point in the event of a building
3.11.3
evacuation?
3.11.8
Explain your understanding of the UQ Wellness program?
W2 Comments:
Recommendations:
W3 Comments:
Recommendations:
W4 Comments:
Recommendations:
Location 1: Location 3:
Location 2: Location 4:
Criteria Items L1 L2 L3 L4
3.5.1 Dedicated OHS Notice Board
3.5.1 UQ OHS Policy displayed / available
3.5.1 WHSC contact details displayed
3.5.1 HSR contact details displayed
3.5.1 First Aid Officer name displayed near first aid kit
3.7.2 SOPs displayed (if required, relevant to the level of risk)
3.8.1 Displayed OHS information is up--to--date
3.8.2 Local OHS documents include date and version number
3.8.4 Local OHS documents reviewed at least every 3years
3.10.1 Facility security appropriate to the level of risk
3.10.1 Laboratories have UQ “CAUTION” sign on door
3.10.1 Hazardous and/or specialised areas and rooms signed
3.10.9 UQ “Guide to Laboratory Waste Disposal” displayed
3.10.9 Waste stored safely prior to appropriate disposal
3.10.10 Good housekeeping – facilities / equipment maintained
3.10.12 SDS’s readily accessible (in event of emergency)
3.10.13 Sufficient chemical storage cabinets
3.10.13 Hazardous chemicals and DGs stored safely / correctly
3.10.13 Chemical substances in appropriate containers
3.10.13 Chemical containers in good condition
3.10.15 PPE available and maintained in good condition
3.10.16 Equipment appropriately guarded
3.10.16 Equipment maintained and records kept
3.10.16 e.g. Plant / Equipment Register available and up--to--date
3.10.16 Electrical items safety tested (where applicable)
3.10.16 Power boards compliant (e.g. individually switched)
3.10.17 Appropriate use of “Out--Of--Service” tags
Criteria Items L1 L2 L3 L4
3.10.25 Chemicals labelled correctly e.g. Chemwatch labels
3.11.1 UQ Emergency Procedures Cards (EPC) displayed
3.11.2 EPC filled out with current information
3.11.2 Building / Emergency / Floor Warden names displayed
3.11.5 Emergency Evacuation Plan displayed
3.11.5 Emergency exits clear (check stairwell)
3.11.5 Emergency equipment tagged and inspected – ‘in--date’?
3.11.5 Safety showers / eyewash stations – tested? Records?
3.11.5 Chemical Spill Kits – fully stocked
3.11.5 Chemical Spill Kits – contents ‘in--date’
3.11.6 Chemical Register/Manifest available and up--to--date
3.11.7 First Aid Kits – signed / labelled
3.11.7 First Aid Kits – fully stocked
3.11.7 First Aid Kits – contents ‘in--date’
3.11.8 EAP brochures displayed
Comments / Recommendations:
L1 Comments:
Recommendations:
L2 Comments:
Recommendations:
L3 Comments:
Recommendations:
L4 Comments:
Recommendations:
NAT attributes heaviest weighting (12) to Elements 3.9 Risk Management Program, 3.10 Hazard ID, Risk
Assessments and Controls. A high priority ranking would be indicated for corrective actions for these Elements.
Otherwise, a high frequency of PCs or NCs for elements other than those specified, may pose sufficient threat to
the OHS management system to indicate a high priority for corrective actions.
2. Medium Matters that are important to the OHS management system (of control?) or success of the business
activity, and should be addressed as soon as possible.
NAT attributes a moderate weighting of 8 to Elements 3.2 Responsibility and Accountability, 3.3 Training and
Competency and a moderate weighting of 5 to Elements 3.4 Consultation and 3.6 Reporting. A medium priority
ranking may be indicated for corrective actions of these Elements. Otherwise, a high frequency of PCs or NCs for
elements other than those specified, may pose sufficient threat to the OHS management system to indicated a
moderate priority for corrective actions.
3. Low Matters which are unlikely to have a significant impact on the OHS management system or success of the
project, but should be addressed as part of continuous improvement.
NAT attributes a lighter weighting of 3 to Elements 3.1 Resources and 3.7 Documentation. A low priority ranking
may be indicated for corrective actions of these Elements. Otherwise, a small number of PCs or NCs in Elements
other than those specified, may pose little threat to the OHS management system to indicate a low priority for
corrective actions.
4. Value Added Recommendations that would, if implemented, enhance the OHS management system or
efficiency of the system. These recommendations are considered as best practice as opposed to OHS
management system weaknesses.