ALBERTA GOVERNMENT OCCUPATIONAL HEALTH AND · PDF fileOCCUPATIONAL HEALTH AND SAFETY: AUDIT...

In certification years certificate is mailed to

Audit Name

Audit Dates

ALBERTA GOVERNMENT

OCCUPATIONAL HEALTH AND SAFETY

AUDIT DOCUMENTMinistry Name

Approved December 3, 2013

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PURPOSE OF AUDIT:

Auditor Qualification COR

Baseline COR Maintenance

Certificate #:

Expiry Date:

A. EMPLOYER INFORMATION

Department or Organization Name:

Division or Worksite Name:(as entered on COR)

Employer WCB Account Number:

Employer WCB Industry Code:

Employer Contact Name:

Employer Contact Title:

Employer Address:(including postal code)

Telephone #:

Fax #:

E-mail:

GOVERNMENT OF ALBERTA

PARTNERSHIPS AUDIT COVER PAGE

Note: Audit Scope needs to be approved by the Public Service Commission before the Audit begins.

Audit Cover Sheet Page 1 of 2

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B. LEAD AUDITOR CONTACT INFORMATION

Lead Auditor Name:

Lead Auditor Department

or Organization Name:

Lead Auditor Address:

Telephone #:

Fax #:

Lead Auditor Signature

C. AUDIT TEAM MEMBERS INFORMATION (excluding Lead Auditor)

RoleDocumentation Review, Observation Tour,

Interviews, Report Writer

Employee I.D. #Name

GOVERNMENT OF ALBERTA

PARTNERSHIPS AUDIT COVER PAGE

Note: Audit Scope needs to be approved by the Public Service Commission before the Audit begins.

Audit Cover Sheet Page 2 of 2

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Audit Start Date:

Audit End Date:

Audit Report Completion Date:

Is Work at Peak Activities?

Yes No

Program

Location Sites Visited

1.

2.

3.

4.

5.

6.

7.

8.

9.

ACTIVITIES

Type Activities Here

ACTIVITIES


ACTIVITIES


AUDIT SCOPE

ACTIVITIES


ACTIVITIES


TOTALS

ACTIVITIES


ACTIVITIES


ACTIVITIES


ACTIVITIES


List ALL Program Areas, Worksites, Bldg. Name, Address, Floor Number Covered in the Scope of the Audit(Work areas and activities performed in work area)

(enter one location,

e.g. Edmonton, etc.)

(enter "x",

if applicable)

Audit Scope Sheet Page 1 of 2

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1.

2.

3.

4.

5.

6.

7.

8.

9.

Interviewed Interviewed Interviewed Interviewed Interviewed Interviewed

0 0 0 0 0 0 0 0 0 0 0 0

Number of Shift

Workers

FULL-TIME - If you are identified in IMAGIS as a Permanent employee and work at least 36.25 hrs/week

PART-TIME - If you are Temporary, Wage Reg, Wage 1450, Wage 2850 and/or work less than 36.25 hrs/week

If you have no direct reports you are a WORKER regardless of your classification

If work is regularly scheduled to occur at any time other than regular business hours (i.e. Monday to Friday

8:15-4:30) it must be properly identified as Shift Work

Full Time Part TimeNumber of Workers Number of

Managers

Number of

Supervisors

Number of

Executive Managers

Audit Scope Sheet Page 2 of 2

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YES NO N/A

1.0 OH&S MANAGEMENT

GoA Occupational Health and Safety Policy (1.3)

Contractor Selection Criteria (1.9)

Samples of Contracts that Identify Health & Safety Responsibilities (1.9)

Contract Compliance Reports, Related Inspection Reports, Incident Investigation

Reports, Follow-up Correspondence (1.9)

A1.0 HEALTH AND SAFETY COMMITTEES

Department Occupational Health and Safety Committee Terms of

Reference/Minutes (A1.1, A1.3, A1.7)

Workplace Health and Safety Committee Terms of Reference/Minutes (A1.2, A1.4,

A1.7)

Workplace Health and Safety Contact Person Records (A1.2, A1.4, A1.7)

2.0 HAZARD MANAGEMENT

Inventory of Jobs/Occupations (2.1)

Inventory of Tasks/Activities (2.2)

Completed Hazard Assessment Documents (2.3, 2.4, 2.14)

Written Safe Work Practices/Job Procedures/Codes of Practice/MSDS (2.7)

Lockout/tag out process and reporting forms/tags (2.17)

3.0 OH&S Training

Employee Training Records (A1.6, 2.13, 3.2, 3.3, 4.6, 5.8, 6.7)

4.0 INSPECTION

Written Policy/Procedure for Conducting Inspections Including Frequency (4.1)

Completed Inspection Checklists and Related Correspondence (4.2, 4.3, 4.5)

5.0 EMERGENCY PREPAREDNESS

Emergency Preparedness Plans (5.1, 5.2, 5.4)

Emergency Response Drill Reports/Follow Up Records (5.7)

DOCUMENT LIST

The documents listed below are required to verify information related to the specific audit questions in brackets.

The completed checklist indicates the documents have been reviewed during the audit.

Documentation Review

Document List Page 1 of 2

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YES NO N/A

6.0 INCIDENT MANAGEMENT

Incident Reporting and Investigation Procedure (6.1)

Completed Supervisor's Incident Investigation Reports (6.3, 6.4)

Incident/Injury Statistical Reports (6.5)

7.0 PROGRAM EVALUATION

Occupational Health and Safety Annual Plan (7.1, 7.3)

Previous Audit Report for information (7.1)

Observation Tour

Other documents need to be assessed during the audit observation tour to verify the specific audit questions in brackets.

Occupational Health and Safety Legislation, and other legislation as required (1.2)

Meeting minutes for the Workplace Health and Safety Committee or Contact (A1.5)

Administrative Controls such as Safe Work Practice or Procedures, Codes of Practice (2.8)

Document List Page 2 of 2

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EXECUTIVE SUMMARY

INTRODUCTION

Type Info Here.

For a hard return remember to use ALT + ENTER.

To expand your cell place your cursor below line number and double click left mouse button.

SCOPE

Type Info Here.



PROGRAM STRENGTHS

Type Info Here.



IMPROVEMENT OPPORTUNITIES

Type Info Here.



RECOMMENDATIONS

Type Info Here.



CONCLUSIONS

Type Info Here.



Executive Summary Page 1 of 1

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D/I/OPoint

ValueScore

1.0 Occupational Health and Safety Management

1.1

Employees are familiar with relevant occupational

health and safety (OH&S) legislation. Verified by interviews with Executive Managers, Managers,

Supervisors and Workers

All employees should be able to explain OH&S legislated

requirements outlined in the Act, Regulation and Code that apply to

the work that they do. Other sources of legislation may also apply

to them such as the Alberta Fire Code or Building Codes,

Transportation of Dangerous Goods etc. They must be able to

also explain how this legislation applies to their work.

Points are awarded based on the percentage of positive

responses from employees interviewed. Provide examples.

I (all) 0-10

1.2

Health and safety legislation is available to

employees at all workplaces.Verified by observation of the workplaces

Current versions of Alberta’s Occupational Health and Safety Act,

Regulations and Code must be available to all employees. If the

legislation is available electronically employees must be able to

demonstrate how they access it. A reliable source of internet

service must be present in order for the online access to be

acceptable.

All points are awarded if observations indicate current

legislation is available at all workplaces. Provide examples.

O 5

Auditor Notes / RecommendationsAudit Scoring

Audit Questions / Instructions

Element 1.0 OHS Management Page 1 of 6

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1.3

The health and safety policy for the Government of

Alberta is available at all workplaces. Verified by review of documentation

The Government of Alberta (GoA) Occupational Health and Safety

Policy is signed by the Public Service Commissioner and endorsed

by the President of the Alberta Union of Provincial Employees

(AUPE).

The policy is written in the GoA OH&S Program and must be

available in hard copy or online to employees at all workplaces.

All points are awarded if documentation is in place. Provide

examples.

D 5

1.4

Employees are aware of the health and safety

policy for the Government of Alberta. Verified by interviews with Executive Managers, Managers,


Employee responses should demonstrate an understanding that

the GoA OH&S Program is built collaboratively with the AUPE; that

everyone has a shared responsibility to follow the GoA OH&S

Program at their workplaces; and that health and safety practices

are integrated with business operations and individual activities.



I (all) 0-5


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1.5

The Deputy Minister/Assistant Deputy Minister

demonstrates the Department's commitment to

health and safety with employees. Verified by interviews with Managers, Supervisors and Workers

Commitment to health and safety within the department may be

demonstrated through communications that outline approval and

communication of any department specific OH&S procedures and

practices; department OH&S goals and plans; by providing

leadership to executive management on health and safety

initiatives; and by communicating and recognizing department

results and employee accomplishments for health and safety

performance.

Interview responses should illustrate how the commitment of the

Deputy Minister, and Assistant Deputy Minister, to health and

safety has been demonstrated.

Initiatives by the Department Health and Safety Committee and the

policy statement from Question 1.2 are not included in this

question.



I (m,s,w) 0-10

1.6

Health and safety responsibilities have been

assigned for all employees. Verified by interviews with Executive Managers

Specific tasks and activities related to the implementation of the

GoA OH&S Program and effective operation of health and safety

practices and procedures must be assigned to employees at all

levels within a business unit. Senior managers are accountable to

ensure employees have assigned health and safety responsibilities

and are measured on their performance.



I (em) 0-5


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1.7

Employees at all levels of the organization are

familiar with their assigned health and safety

responsibilities. Verified by interviews with Executive Managers, Managers,

Supervisors, and Workers

Employees should be able to discuss their assigned health and

safety responsibilities and authorities included in their annual

performance plans, job descriptions and responsibilities outlined for

them in the GoA OH&S Program.



I (all) 0-10

1.8

Workers receive information, and can provide

feedback, on health and safety issues. Verified by interviews with Workers

Employees must be able to describe methods in which they receive

health and safety information and how they can provide feedback

on the information they have received. Communication methods

may include minutes of staff meetings, incident bulletins, health

and safety newsletters, memoranda etc.



I (w) 0-15


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1.9

There is a process in place to ensure contracted

employers fulfill their legislated responsibilities

under the OH&S Act, Regulation and Code. Verified by review of documentation

All employers are required to meet the responsibilities of health and

safety legislation. The nature of the contracted work may provide

different levels of risk, which may result in not all of the criteria

listed being required. A sample of contracts should be reviewed

which may be present under various terminology - i.e. Service

Agreements, Fee for Service, short form and long form General

Services etc..

The process will include:

• OH&S selection criteria for contracted employers; 5

• the contract must identify health and safety responsibilities of

contracted employers;

5

• a process to monitor health and safety performance for

contracted employers during the period of the contracted services

and to correct identified deficiencies;

5

• a process to evaluate any improvement opportunities for future

contracts

5

5 points are awarded for each criterion if documentation is

in place. If specific criteria are not required for low or

medium risk operations they may be eliminated through the

use of a “not applicable” and a full explanation must be

provided. High risk operations (as defined in the OH&S

Code, Schedule 2, Table 2) are evaluated for all four

criteria.

D


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1.10

Sufficient resources are provided by the employer

to implement and improve health and safety. Verified by interviews with Executive Managers

Department Deputy Ministers/Executive Managers have the

responsibility to allocate funds, time and human resources to

implement, maintain and evaluate the operation of the GoA OH&S

Program, Goal and Plans within the Department. Resources

include such things as the provisions of health and safety

professionals or expertise, funding made available to implement

controls identified in hazard assessment and control reports, or

funding to implement corrective measures or correct deficiencies

identified in investigation and inspection reports.


responses from employees interviewed.

Provide examples.

I (em) 0-10

1.11

Health and safety records are retained. Verified by review of documentation

Records must confirm that the standard forms contained within the

GoA OH&S Program are being used for documentation of health

and safety events at the workplaces. This will include Hazard

Management forms, Incident Management forms, and OH&S

Management forms. The workplace where the document

originated must have a completed version of the document. There

must be evidence that forms are being maintained according to

proper GoA OH&S Program retention schedules and maintain any

applicable levels of confidentiality.

Documentation of other events such as site specific workplace

inspections checklists, health and safety orientation checklists, and

records of emergency response exercises must also be retained.

All points are awarded if documentation is in place.

D 10

Element Total 105 0


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A1.0 Health and Safety Committees

A1.1 There is a Department Health and Safety

Committee operating in accordance with the

Government of Alberta OH&S Program. Verified by review of documentation

Terms of Reference and meeting minutes must confirm the

existence of an operational Department Health and Safety

Committee.

The Terms of Reference must include an appropriate

representation of management/opted out or excluded and

bargaining unit representatives; executive sponsorship or

participation of an Executive Team member on the committee

must also be documented; and outline the frequency at which

meetings will be held.


D 10


Audit Scoring

Auditor Notes / Recommendations

Element A1.0 Health Safety Committees Page 1 of 6

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ScoreAudit Questions / Instructions

Audit Scoring


A1.2There is a Workplace Health and Safety Committee

(or Contact in lieu of a committee) operating at the

workplace in accordance with the Government of

Alberta OH&S Program. Verified by review of documentation

Terms of Reference and meeting minutes must confirm the

existence of an operational Workplace Health and Safety

Committee.

Terms of Reference must identify the workplaces included within

the scope of the committee, identify an appropriate representation

of management/opted out or excluded and bargaining unit

members and outline the frequency at which meetings will be held.

The number of non-union representatives cannot exceed the

number of union representatives on the committee.

Administrative workplaces may have a Workplace Health and

Safety Contact person acting in lieu of a committee.

Documentation may be present in the form of meeting minutes or

email communications between the contact and the Workplace

Manager. WHS Contacts are required to complete an activity

report annually.


D 10


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A1.3

The Department Health and Safety Committee

performs its responsibilities in accordance with the

Government of Alberta OH&S ProgramVerified by review of documentation

Meeting minutes for the Department Health and Safety Committee

should confirm:

• issues addressed by the committee have a department wide

impact;

• the committee reviews annual evaluations of workplaces within

their scope;

• it reviews and supports the implementation of the Department’s

annual health and safety plan;

• members attend meetings regularly;

• minutes are approved by both management/opted out/excluded

and bargaining unit co-chairs (copies of the meeting minutes are

sent to the Deputy Minister, department Human Resource

Services and the AUPE)

• meetings occur at least three times per year.


D 10


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A1.4Workplace Health and Safety Committees and

Contacts perform their responsibilities in

accordance with the Government of Alberta OH&S

Program. Verified by review of documentation

Meeting minutes for WHS Committees should confirm:

• meetings are occurring at the frequency defined within the Terms

of Reference;

• members, or alternates, are regularly attending the meetings;

• members are reviewing incident summary reports;

• members are participating in workplace inspections;

• the status of identified hazards and concerns discussed;

• other events planned and activities completed or their status;

• and are making recommendations to the Workplace Manager

that support the operation of the health and safety program within

the workplace.

• minutes are approved by both management/opted out/excluded

and bargaining unit co-chairs

Administrative workplaces require a Workplace Health and Safety

Contact person acting in lieu of a committee. Documentation must

show that Contacts are conducting annual inspections of their

workplace; accepting employees’ health and safety concerns and

utilizing the Issue Resolution Process as needed; reviewing

incident summary reports; and documenting any other health and

safety events or activities organized by the Contact.


D 20


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A1.5

Meeting minutes for Workplace Health and Safety

Committees are maintained and are available to

employees at all workplaces.Verified by observation of the workplaces

Meeting minutes of the health and safety committee must be

available to employees. Original minutes and records of all

committee activities are maintained by the committee secretary.

They may be posted in a visible location or available electronically.

Points are awarded based on the percentage of locations

where meeting minutes were available compared to the total

number visited. Provide examples.

O 0-10

A1.6Workplace Health and Safety Committee members

or Contacts have taken the required health and

safety training. Verified by review of documentation

Training records of all committee members or contacts must show

they have taken the required training identified in the GoA OH&S

Program within their first year of appointment.


D 5


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A1.7

Established timelines within the Issue Resolution –

Standard Process are met to ensure identified

issues are resolved in a timely manner.Verified by review of documentation

The issue resolution process begins after the employee has

discussed the concern with his/her supervisor and the supervisor

has failed to satisfy the employee’s concern; and the Workplace

Health and Safety Committee or Contact validates the concern as

a health and safety issue in accordance with the Issues Chart

within the GoA OH&S Program. Specific timelines, outlined within

the program, must be met in order to comply with the standard

process. Documentation must show timelines have been met.

Meeting minutes include the status of validated health and safety

issues and recommendations made to supervisors and managers.

Points are awarded based on the percentage of issues

resolved within the established timelines compared to the

total number of issues. Provide examples.

D 10

A1.8 Employees are familiar with the functions of the

Department and Workplace Health and Safety

Committees or Contact.Verified by interviews with Executive Managers, Managers,


Employees should be able to describe how the Department and

WHS Committees or Contact promote a healthy and safe

workplace. This should include identification of the members of

the committee or Contact who represents them; health and safety

activities that are organized by the committees or Contact; and the

methods used by the committees or Contact to communicate their

operations to the workplaces.



I (all) 0-10

Element Total 85 0


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2.0 Hazard Management

2.1

Workplace specific Occupation Inventory forms

have been completed for all jobs and occupations. Verified by review of documentation

A detailed list of all employee jobs and occupations must be

available to compare to the staff listings for the area being audited.

The inventories must be specific to the workplace and must have

been reviewed within the previous three years.

Points are awarded based on the percentage of jobs and

occupations inventoried compared to the number required

as identified on staff listings or organizational charts.

Sampling is not acceptable for scoring this question.

D 0-25

2.2

Task Inventory forms have been completed for all

jobs and occupations in question 2.1. Verified by review of documentation

A list of job-specific tasks and activities must be available to

compare to the Occupation Inventory listings in Question 2.1

If no Occupation Inventory is available, or it is incomplete, the Task

Inventories must be compared to the staff listings or organizational

charts in order to verify they are complete. The inventories must

have been reviewed within the previous three years.

Ensure highway motor vehicle operation is considered if driving is a

frequent activity.

Points are awarded based on the percentage of Task

Inventory forms completed compared to the jobs and

occupations identified in 2.1 or to the staff listings. Sampling

is not acceptable for scoring this question.

D 0-25


Audit Scoring


Element 2.0 Hazard Management Page 1 of 12

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2.3

Hazard Assessment and Control Report forms

have been completed, and include all identified

tasks and activities, for each job and occupation at

the workplace. Verified by review of documentation

Hazard Assessment and Control Reports must demonstrate that

existing and potential health and safety hazards have been

identified for the tasks and activities listed in the Task Inventories

for each job or occupation. The reports must have been reviewed

within the previous three years.

Hazard Assessment and Control Reports must be available to

employees at all workplaces. If employees at a workplace are

unable to access the reports the score will be reduced accordingly.

Points are awarded based on the percentage of reports

completed compared to the total number required from the

inventories. Sampling may be necessary for scoring this

question.

The maximum score available for this question will be

determined by the total score awarded in question 2.2.

D 0-40


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2.4Health and safety hazards have been evaluated to

determine their level of risk and prioritized to

determine the order of importance to implement

controls. Verified by review of documentation

Hazard Assessment and Control Reports must demonstrate that a

process is in place to identify and prioritize the risk of health and

safety hazards for the tasks and activities listed in the inventories.

Degree of risk is based on an evaluation of the: Frequency of

employee exposure to the hazard; potential consequence of

exposure to the hazard; probability of an incident occurring.

Frequency x Potential x Probability = Risk

The risk analysis on the hazard assessment will assign an overall

rating for the degree of risk. The degree of risk must be prioritized

as High, Medium, or Low in order to establish the order of

importance to implement controls.

Hazard Assessment and Control Reports must be available to

employees at all workplaces.

All points are awarded if documentation shows the degree

of risk has been determined and prioritized. Sampling may

be necessary for scoring this question.

D 5


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2.5

All workers have participated in the identification

of applicable hazards and the implementation of

controls for their work and their workplace(s). Verified by interviews with workers

Interview responses must demonstrate that workers have

participated in the assessment, elimination and control of hazards

for their work and workplace. They should be able to describe the

process in which they participated in the development of their

hazard assessment(s), and/or that they reviewed the hazard

assessment for their job or occupation with the Hazard Assessment

Lead or their Supervisor, and it is directly applicable to the work

they do, the conditions under which they perform their work, the

equipment they use, and the controls in place at their workplace.



I (w) 0-20

2.6 Engineering controls identified in Hazard

Assessment and Control Reports have been

implemented. Verified by observation of the workplaces

Engineering controls must be available to employees at the

workplace for which they have been identified in the Hazard

Assessment and Control Reports.

Implemented means the controls are in place and functional.

Points are awarded based on the percentage of engineering

controls that have been implemented at the workplace

where it is required compared to the number selected from

hazard assessments. Provide examples.

O 0-15


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2.7Administrative controls identified in Hazard

Assessment and Control Reports have been

written. Verified by review of documentation

Safe Work Procedures are written step by step instructions

required to safely perform a task from beginning to end.

Safe Work Practices are written guidelines that help in the safe

performance of a task that may not always be done in a specific

way.

A Code of Practice is required for any respiratory protective

equipment in use at the workplace, confined space entry and the

use of chemical substances and processes listed in Schedule 1,

Table 1 of the OH&S Code. Any NIOSH approved respiratory

protective equipment (i.e. N95 masks) in use at the workplace

require a Code of Practice.

Material Safety Data Sheets (MSDSs)are required for harmful

substances that are controlled products and/or may have an

adverse effect on employees or occupants of the facility. MSDSs

must have preparation or revision dates within the past three years.

Correspondence to the supplier requesting new MSDSs must be

on file if they are outdated. Correspondence must be dated within

the past three months of the audit dates.

Points are awarded based on the percentage of

administrative controls that have been written compared to

the number selected from hazard assessments. Provide

examples.

D 0-10


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2.8

Administrative controls are available to employees

at the workplace(s). Verified by observation of the workplace(s)

Written Safe Work Procedures/ Practices/Codes of Practice,

MSDSs or any other administrative control in the form of a written

document must be available to employees at the workplace for

which they have been identified on the Hazard Assessment and

Control Reports.


administrative controls that are observed at the

workplace(s) where it is required compared to those

selected from the hazard assessments. Provide examples.

O 0-15

2.9

Required Personal Protective Equipment (PPE)

identified in the Hazard Assessment and Control

Reports is available to employees for use. Verified by observation of the workplaces

Examples of common PPE are chemical or puncture resistant

gloves, respirators that meet NIOSH standards, hard hats that

meet CSA or ANSI standards, hearing protection that meets CSA

standards, foot protection that meets CSA, ASTM or NFPA

standards, eye protection that meets CSA or ANSI standards.

Other standards may be identified in the adopted code for that

activity.

Points are awarded based on the percentage of PPE

available to employees for use at the workplace where it is

required, compared to those selected from hazard

assessments. Provide examples.

O 0-15


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2.10Where Personal Protective Equipment (PPE) is

identified on the Hazard Assessment and Control

Report as a method of control, employees are

trained in the proper selection, use, care and

maintenance of the PPE. Verified by interviews with Managers, Supervisors and Workers

Employees must be able to describe the method of training they

received on the proper selection, use, care, and maintenance of

the PPE they are required to use.



I (m,s,w) 0-15

2.11

Employees are using the controls for the identified

health and safety hazards on the Hazard

Assessment and Control Report. Verified by observation and interviews with Managers, Supervisors

and Workers

Interview responses must indicate that workers are using

engineering and administrative controls and PPE.

Points are awarded if observations indicate the controls are

in place, in use AND at least 70% of interviews are positive.

Provide examples for both techniques.

O AND I

(m,s,w)

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2.12

Managers and supervisors ensure the employees

use of engineering controls, administrative

controls and personal protective equipment. Verified by interviews of workers

Workers must be able to discuss how supervisors and managers

ensure the use of required controls at the workplace. The process

may be a formal disciplinary process that includes verbal reminders

and written reprimands, as well as recognition of positive

behaviors.



Provide examples.

I (w) 0-15

2.13

Employees assigned as hazard assessment leads

have completed the required training. Verified by review of documentation

Training records for identified hazard assessment leads must show

that they have taken the required training since the implementation

of the revised GoA OH&S Program was released in 2009.


D 5


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2.14The Hazard Assessment and Control Reports have

been completed by a hazard assessment lead in

consultation with employees who perform the

work. Verified by review of documentation and interviews with Executive

Managers and Managers

Employees trained as hazard assessment leads must have been

involved in the process of developing hazard assessments with

employees who perform the task or activity to ensure the report is

accurate. The involvement by the Lead must be present in the form

of a signature on the reports. The training of the Lead identified on

the reports must be verified by the audit team through review of

their training records.

All points are awarded if documentation is in place AND at

least 70% of interview responses are positive.

D AND I

(em,m)

10


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2.15

Hazard assessments are reviewed according to

Government of Alberta OH&S Program

requirements. Verified by interviews with Managers and Supervisors

Hazard assessments must be reviewed and revised according to

provincial OH&S legislation requirements, GoA OH&S Program

requirements and as a result of inspection or investigation findings.

The hazard assessment process must be repeated:

• when a new work process or new equipment is introduced;

• when a work process or operation change;

• when or before the construction of significant additions or

alterations to the workplace are made;

• when new hazards are identified, new controls are implemented

or controls for hazards are modified as a result of an inspection,

incident investigation, emergency exercise or emergency;

• and at least every three years.

Interview responses must demonstrate that managers and

supervisors are aware that hazard assessments are reviewed and

revised periodically, and give examples of when this has happened

at their workplaces due to the listed criteria.



I (m,s) 0-30


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2.16

Equipment is maintained according to its

manufacturer's specifications. Verified by interviews with Supervisors and Workers

Equipment (for example: vehicles, mobile equipment, tools,

supplies, machinery, and sanitary facilities) must be maintained in

a condition that adheres to the manufacturer’s specifications and

will not compromise the health or safety of employees using or

being transported by them.

Schedules should be available for each piece of equipment and

based on the manufacturer’s specifications for maintenance and

servicing. These may be in the form of log books, inspection

checklists or databases.

Typical office equipment is not included.

Supervisors and workers should be able to describe how

equipment is maintained within their business unit.



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2.17There is a procedure in place to prevent the use of

defective equipment by employees. Verified by review of documentation and observation of the

workplaces

An important part of equipment maintenance is knowing the

process to report and record defective equipment that fails during

use, and isolating or controlling hazardous energy so that defective

equipment is not used by others. If tags, signs, locks or other

energy isolating devices are used, training must also be provided

to employees who are required to control and isolate the hazardous

energy of the defective equipment.

Documentation will include the process and may also include

reporting forms, new or used warning tags or a computerized

program or database.

Observation should identify examples of equipment or machinery

that has been removed from service. If none are readily available

the auditor should inquire regarding the process.

All points are awarded if documentation is in place AND the

procedure is observed to be in use. Provide examples for

both techniques.

D AND O 20

Element Total 295 0


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3.0

3.1

Employees receive health and safety orientation

that includes:

• Roles and responsibilities for workers,

supervisors and managers; locations of first aid

supplies and services; (0-5 points)

• Health and safety procedures such as: emergency

response; imminent danger; and reporting

incidents; (0-5 points)

• And it occurs within the first week of

commencement. (0-5 points)Verified by interviews with workers

Health and safety orientation must be provided by the supervisor of

both new employees, and employees who are assigned a new job

or who are relocated. Orientation for employees must provide

workplace specific information on health and safety topics that

include hazards specific to their assigned duties and workplace,

emergency response plans for their location, procedures for

emergency response, the location of first aid services and supplies,

incident notification procedures and responsibilities for health and

safety of the employee, their supervisor or manager and the

employer.



Provide examples in each category.

I (w) 0-15


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Occupational Health and Safety Training

Element 3.0 OHS Training Page 1 of 5

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Occupational Health and Safety Training3.2

Employees receive job specific health and safety

training before they begin a newly assigned task.

Managers (0-5 points)

Supervisors (0-5 points)

Workers (0-5 points)Verified by review of documentation

Health and safety training must be provided to all new employees

before they begin the task; and all employees before they start

working on a newly assigned task. This training must include the

review and revision (if needed) of hazard assessments for the task,

instruction specific to the employee’s tasks and work area, specific

requirements identified in and required by the hazard assessments,

instruction on safe work procedures, instruction on emergency

response procedures, how to use, select and maintain personal

protective equipment, how to safely use equipment, and instruction

on harmful substances employees will work with or be exposed to.

Training records must show that employees receive the training

specified on their Hazard Assessment and Control Reports to

safely perform their assigned duties. Other methods of identifying

training needs may include Safety Training Needs Assessment

templates or training matrices.

Points are awarded based on the percentage of employees

in each category who have received the required training

identified in hazard assessments, Safety Training Needs

Assessment templates or training matrices, compared to the

total selected. Provide examples in each category.

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Employees receive refresher training to maintain

certifications and remain competent to perform

their assigned tasks.Verified by review of documentation

Training records must show that employees who require refresher

training to maintain competency in their assigned duties receive the

required training. If the hazard assessment for that employee or

their tasks requires the training, then it must be maintained.

This may include seasonal refresher training, trade and skills

upgrading, review of safe work procedures or practices, WHMIS,

First Aid (3 years), Transportation of Dangerous Goods (Road 3

years, Air 1 year), control tactics, firearms, emergency vehicle

operations, defensive driving, confined space entry, respiratory

protective equipment.

Departments may establish their own timelines for refresher training

in these areas, if there is no legislated requirement, through the use

of a training needs assessment or matrix.

Points are awarded based on the percentage of employees

who have received the required training compared to the

number selected. Provide examples.

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Visitors and contractors receive health and safety

orientation to the workplace. Verified by interviews with Executive Managers, Managers,


Contractors and visitors require orientation to workplace health and

safety requirements. Topics include the location of first aid

supplies and services, emergency response procedures for the

facility, known hazards at the workplace.

External auditors are visitors to the workplace.



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Occupational Health and Safety Training3.5 Managers verify that employees have the

qualifications, training and experience to perform

their assigned tasks safely. Verified by interviews with Executive Managers and Managers

Management is responsible to ensure that employees have the

qualifications, training and experience to perform their assigned

duties safely with little or no supervision.

Qualifications may be earned through a formal educational

program, training course or a combination of education and

practical experience.

Training must be appropriate to the tasks and equipment that will

be performed or used and sufficient experience may be evaluated

during the length of time that work is performed under supervision.

The employer is ultimately responsible to ensure workers are

competent.

Management must be able to describe the process employees

undergo to ensure they are competent prior to performing assigned

duties unsupervised.



I (em,m) 0-20

Element Total 80 0


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4.0

4.1Management has developed inspection schedules

for their operations and workplaces which meet or

exceed the requirements outlined in the

Government of Alberta OH&S Program Standard

Process.Verified by review of documentation

Managers must develop inspection schedules for their operations

and workplaces based on the frequencies given in this standard

process. The schedules should include inspection timeframes,

which operations and workplaces will be inspected, and who will

carry out each inspection.

The GoA OH&S program outlines minimum inspection frequencies

for types of workplaces based on continuous use. Workplaces

may require more frequent inspections during periods of high

activity, if the number of hazards related to equipment used and

activities at the workplace changes, or if the frequency or number

of incidents increases.

A department policy may also outline the frequency of inspections

for workplaces other than those in the GoA OH&S Program.


D 15

4.2

Workplace inspections are conducted at the

frequency according to the Government of Alberta

OH&S Program requirements. Verified by review of documentation

Documentation must show that inspections are being carried out

at the frequency defined within the inspection schedules in

Question 4.1.

Points are awarded based on the percentage of inspections

that meet the required frequency.

D 0-10


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Inspections

Element 4.0 Inspections Page 1 of 4

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Inspections4.3 Inspections are conducted using a workplace

specific checklist. Verified by review of documentation

Equipment and site-specific checklists for operations and

workplaces within the business unit must be utilized. They

document observations and the corrective measures implemented,

and are the record of inspection. Inspections conducted by

Workplace Health and Safety Committees should have the

findings of their inspections also recorded in their meeting

minutes.


D 10

4.4

Identified deficiencies on inspection checklists are

corrected. Verified by review of documentation and observation of the

workplaces

Managers are required to prioritize and verify that corrective

measures are immediately implemented for substandard

conditions and defective equipment identified during the inspection

and/or on the inspection report. The manager may delegate the

implementation of the corrective measure to the supervisor.

Points are awarded based on the percentage of deficiencies

selected from checklists that are observed to be corrected.

Provide examples

D

AND

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Inspections4.5Managers have signed completed checklists

verifying all identified corrective measures have

been implemented. Verified by review of documentation

Managers must review inspection checklists. They are signed off

by managers at a higher level than those conducting the

inspection.

Points are awarded based on the percentage of inspection

checklists signed by management compared to the total

number selected.

D 0-10

4.6 Employees assigned by management as

inspection leads have completed the required

training. Verified by review of documentation

Inspection checklists must identify employees conducting the

inspection. Comparison to training records must show that the

employee assigned as the inspection lead has completed the

required training since the GoA OH&S Program was revised in

2009.


D 5


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Inspections4.7

Employees are familiar with the process to report

unsafe or unhealthy conditions and practices. Verified by interviews with Executive Managers, Managers,

Supervisors, and Workers

Employees must be able to describe a process in which they can

bring forward concerns regarding unsafe or unhealthy conditions

at their workplaces. All employees are encouraged to identify

concerns that may affect their own or their co-workers’ health and

safety. An employee who becomes aware of a health and safety

concern at the workplace shall immediately notify the supervisor.



I (all) 0-20

Element Total 90 0


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5.0

5.1There is a written emergency response plan for

each type of potential emergency at each

workplace. Verified by review of documentation

Management is responsible to identify potential emergencies in

relation to the operations of the workplace, and to maintain current

written emergency response plans for each type of potential

emergency. The plans are developed and maintained in

consultation with employees. Plans must be reviewed and updated

annually or when changes at the workplace occur.

Workplaces must be assessed for their need for plans specific to

the following potential emergencies:

• Fire;

• severe weather;

• medical emergencies;

• hazardous materials release;

• workplace violence;

• suspicious persons;

• suspicious letters or packages;

• and other situations appropriate for the nature of the work being

performed (for example, working alone).

All workplaces within the scope of the audit must have site specific

procedures or a plan available to employees.

Points are awarded based on the percentage of documented

procedures in place in relation to the number required from

the list above. (0-20 points) Provide examples.

D 0-20


Audit Scoring


Emergency Preparedness

Element 5.0 Emergency Preparedness Page 1 of 6

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Emergency Preparedness5.2

The emergency response plan includes:

• The name and address of the workplace

• The type of potential emergency

• Alarm and Communication procedures (two-way

radios, personal trackers, cellular phones etc.)

• Emergency Phone numbers for emergency

services (police, fire, ambulance, utilities etc.)

• List of assigned emergency response personnel

trained to respond to the type of emergency to be

contacted

• Appropriate response procedures for employees,

visitors and contractorsVerified by review of documentation

The Facility Emergency Response Plan is a manual that provides

templates and guidance. Unless it is modified to be specific to the

workplace and the potential emergencies of the location and work

performed it will not be considered for the purposes of this

question.

Points are awarded in each category if documentation is in

place. (3 points each to a maximum of 18 points)

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Employees understand their responsibilities for

each emergency procedure under the plans. Verified by interviews with Executive Managers, Managers,


Employees should be able to discuss the procedures for potential

emergencies at their workplace and their responsibilities related to

them. This should correspond with identified responsibilities within

the plans.



I (all) 0-20

5.4 Workers have designated responsibilities for

emergency response procedures at their

workplace.Verified by review of documentation

Workers may be assigned by the manager as emergency

response personnel for a variety of potential emergencies at their

workplace. They may be involved in the annual review and update

of the emergency response plan; assigned to maintain first aid

equipment and supplies, and personal protective equipment, in

safe operating condition; assigned to complete emergency

response reports for each exercise and emergency; and must

complete assigned training, maintain the appropriate certifications

and participate in emergency response exercises. Documentation

should demonstrate worker participation, in a leadership role, in

the emergency preparedness processes and procedures at the

workplace.


examples.

D 5


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Emergency Preparedness5.5 Employees are trained on their individual

responsibilities for each potential emergency

identified in the plan. Verified by interviews with Executive Managers, Managers,


Employees must be able to describe the methods of training they

have had on the workplace specific emergency response plans in

order to maintain their competency to respond to emergencies.

Employees with designated responsibilities as emergency

response personnel (i.e. designated first aiders, rescue and

evacuation personnel) may have also received additional training

provided by outside service providers such as the fire department,

police department or independent resources for confined space

rescue or H2S events.



Provide examples.

I (all) 0-20

5.6

Emergency exercises are held at least annually, for

each response procedure identified in the plans to

verify its effectiveness. Verified by interviews with Managers, Supervisors and Workers

Emergency exercises are required at all workplaces to maintain

the competency of the workplace occupants and emergency

response personnel to respond. Exercises could be documented

in Emergency Reports, staff meeting minutes where a plan was

reviewed, or specific meetings designed to review responsibilities

under the plans.

Examples given by employees during the interviews should be

verified by the audit team as part of documentation review.



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Emergency Preparedness5.7Deficiencies identified through emergency

response drills or actual emergencies are

corrected. Verified by review of documentation and observation of the

workplaces

Deficiencies identified during emergency response drills or during

actual emergencies have recommendations for corrective actions

outlined and they have been implemented.

Points are awarded based on the percentage of corrective

actions implemented compared to the number selected from

documentation. Provide examples.

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First aid supplies and services are available

according to Government of Alberta OH&S

Program requirements. Verified by review of documentation and observation of the

workplaces

Check the current first aid legislation in the OH&S Code and verify

the requirements based on total number of workers at the

workplace(s) and the number of workers per shift.

Determine if the workplace is a low, medium or high hazard

workplace. Determine if the workplace is a close, distant, or

isolated workplace.

Confirm that there are adequate numbers of qualified first aiders

across all shifts and workplaces. Training records for employees

designated as first aiders, or requiring first aid training as identified

in their hazard assessment, must show that they have current

certification. Standard (2 day) First Aid is the minimum

requirement. All employees performing field work and lone

employees at a workplace must have Standard First Aid.

Compare the contents of all available first aid kits against the

requirements in the GoA OH&S Program using the criteria

determined above.

All points are awarded if documentation is in place AND first

aid supplies and services meet program requirements.

D AND

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20

Element Total 138 0


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6.0

6.1There is a written procedure that requires the

reporting and investigation of occupational injuries

and illnesses. Verified by review of documentation

Two types of incident classifications require reporting and

investigation: incidents that involve employees and require

reporting based on near miss, treatment or loss, such as serious

incidents, medical aid or lost time; and incidents that have

reporting requirements based on the type of incident, such as

those that involve damage to GoA owned or leased property,

dangerous goods incident or environmental release incidents.

Incident investigations help determine what happened, how it

happened and what needs to be done to prevent the incident from

recurring without assigning blame or fault.

The written procedure for reporting incidents and the standard for

investigating all incidents is written in the GoA OH&S Program and

must be available at all workplaces.


D 5

6.2Employees are knowledgeable of their

responsibility to report work-related incidents

according to the procedures in the Government of

Alberta OH&S Program. Verified by interviews with Managers, Supervisors and Workers

All employees are required to report all work-related incidents to

his or her immediate Supervisor, therefore they must know what

type of incidents that includes. Consider the nature of the work

being performed when evaluating examples provided.



Provide examples.

I (m,s,w) 0-15

Audit Questions / InstructionsAudit Scoring


Incident Management

Element 6.0 Incident Management Page 1 of 4

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Incident Management6.3Investigations focus on the identification of

contributory and direct causes. Verified by review of documentation

Incident investigations help determine what happened, how it

happened and what needs to be done to prevent the incident from

recurring without assigning blame or fault.

Contributory causes are the underlying indicators detailing why an

incident occurred. Direct causes are the immediate cause of why

an incident occurred.

Contributory causes of an incident can relate to people, equipment

or other issues. For example, physical capability, knowledge and

skill or leadership and supervisions are considered people factors.

Purchasing, engineering and maintenance can all be examples of

equipment and material factors contributing to an incident. Other

contributory factors may include workplace conditions,

temperature extremes, improper or inadequate training, safe work

practices, workplace conditions, noise or visibility.

Direct causes are hazardous acts or conditions such as improper

lifting, modification of equipment from its manufactured design,

improper use of equipment for a purpose it was not designed, poor

housekeeping, inadequate guards or barriers, and inadequate or

improper procedures.


investigation reports that identify direct and contributory

causes compared to the total number selected.

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Incident Management6.4 Managers follow-up on work related incidents to

ensure appropriate corrective measures have been

identified and implemented. Verified by review of documentation and observation of the

workplaces

Managers are responsible to review incident details and causes

and assign corrective measures to be implemented. This action

must be completed by the senior manager in the event of a

serious incident, fatality or radiation incident.

Managers must verify that corrective measures have been

implemented and determine if the corrective measures: are

appropriate to eliminate or control the identified hazard; and have

not created additional hazards. Managers must also communicate

the investigation findings and the corrective measures being

implemented.

All points are awarded if documentation is in place AND

observations indicate that corrective measures selected

from investigation reports have been implemented. Provide

examples for both techniques.

D AND O 20

6.5

Incident statistics or records are maintained and

evaluated to identify trends. Verified by review of documentation

Identify examples of the statistics or summaries being maintained

for the area within the scope of the audit. Verify they are

analyzed, and any trends are identified. Trend analysis should

include recommendations and corrective actions to reduce the

incidence within the business unit.

The Workplace Health and Safety Committee or Contact is

responsible to review incident statistics or summaries of incidents

to identify causes and trends and to recommend incident

prevention measures when appropriate.


examples.

D 10


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Incident Management6.6

Managers and Supervisors are responsible for

incident investigations.Verified by interviews with Executive Managers, Managers and

Supervisors

Supervisors, or Managers in lieu of a supervisor, have the

designated responsibility within the GoA OH&S Program to

investigate all health and safety incidents. Interview responses

must indicate they are knowledgeable of this responsibility and

related processes.



I

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6.7

Employees assigned as investigation leads have

completed the required training. Verified by review of documentation

All Supervisors are required to take training to conduct incident

investigations. Employees assigned as investigation leads must

also take the required training to conduct investigations.

Investigation reports must identify the person conducting the

investigation. Comparison to training records must show that

employees conducting incident investigations have completed the

required training since the GoA OH&S Program was revised in

2009.


D 5

Element Total 85 0


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7.0

7.1

Management has developed an annual health and

safety plan for the workplace(s). Verified by review of documentation

Business units must establish a plan, with objectives and

measureable goals, to continuously improve health and safety of

their business operations. If plans have ongoing objectives then

indicators (targets and timeframes) must be found to demonstrate

the item(s) is in progress. Results and recommendations from the

last program evaluation must be incorporated into the development

of health and safety plans for the business units (not required if this

is the first audit for the workplace).


D 30

7.2The health and safety annual plan has been

implemented. Verified by interviews with Executive Managers and Managers

Managers must be able to discuss the goals and objectives

contained within the health and safety annual plan and how they

have been implemented.



I (em,m) 0-15


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Program Evaluation

Element 7.0 Program Evaluation Page 1 of 3

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Program Evaluation 7.3

Workers are involved in the implementation of the

health and safety annual plan.Verified by review of documentation

The health and safety annual plan must identify the name(s) of

workers to whom a particular activity has been assigned. These

workers are responsible to assist in the implementation of the

health and safety annual plan for the business unit(s) being

audited.


examples.

D 10

7.4Employees are familiar with the annual health and

safety plan. Verified by interviews with Supervisors and Workers

Employees must be able to explain the goals and objectives

contained in the annual health and safety plan for their organization

(the units defined within the audit scope).



Provide examples.

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Program Evaluation 7.5 Supervisors and workers are evaluated on and are

accountable for their health and safety

performance. Verified by interviews with Supervisors and Workers

Supervisors and workers must be able to explain the methods used

to evaluate their performance of assigned health and safety

responsibilities. This may include annual performance appraisals,

letters of commendation, positive behavior reinforcement, discipline

for non-performance etc.



Provide examples.

I (s,w) 0-10

7.6All levels of management are evaluated on and are

accountable for the successful implementation of

the health and safety program within their

business units. Verified by interviews with Executive Managers and Managers

Managers are the GoA’s representative for the purposes of

implementing and applying health and safety practices at their

workplaces. Managers allocate funds, time and human resources

to implement, maintain and evaluate the operation of the GoA

OH&S Program, Goals and Plans within their business units. They

demonstrate commitment to health and safety by providing

leadership and direction to their staff in the achievement of OH&S

plans. Managers must ensure the GoA OH&S Program Standard

Processes are implemented for all elements of the program.

All levels of management must be able to explain the methods

used to evaluate their performance of assigned health and safety

responsibilities.



I (em, m) 0-10

Element Total 95 0


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Element Number Element Name Point Value Points Assessed Percentage

1.0 OH&S Management 105 0 0

A1.0 Health and Safety Committees 85 0 0

2.0 Hazard Management 295 0 0

3.0 OH&S Training 80 0 0

4.0 Inspections 90 0 0

5.0 Emergency Preparedness 138 0 0

6.0 Incident Management 85 0 0

7.0 Program Evaluation 95 0 0

973 0 0

Audit Summary Score Sheet

Grand Total

Audit Summary Score Sheet Page 1 of 1

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YES NO N/A

Examples

1.2 Available Legislation is relevant and current.

Strategically located in work areas.

Hard copy readily available to employees or readily

available on line.

A1.5 Meeting minutes are available to employees in hard

copy or online.

Examples

2.6 Randomly select several engineering controls from

hazard assessment documents and confirm their

availability through observation.

2.8 Randomly select several administrative controls

from hazard assessment documents and confirm

their availability through observation.

2.9 Randomly select personal protective equipment

from hazard assessment documents and confirm

their availability through observation.

OBSERVATION TOUR CHECKLIST

OH&S Management

Hazard Management

Observation Tour Checklist Page 1 of 3

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YES NO N/A


OH&S Management2.11 Randomly select several controls from each

category and confirm through observation that

employees are using them.

Engineering Controls

•

•

•

Administrative Controls

•

•

•

Personal Protective Equipment

•

•

•

2.17 Examples of equipment or machinery that has been

removed from service. If none are readily available

inquire regarding the process.

Examples

4.4 Select a sample of corrective actions from

Inspection Checklists and confirm their

implementation through observation.

Inspections


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YES NO N/A


OH&S Management Examples

5.7Selected deficiencies identified in emergency

response drill reports have been corrected.

5.8 First aid supplies and services are available

Kits meet requirements

Are fully stocked and clean.

Vehicle first aid kits are appropriate and available

Examples

6.4 Select a sample of corrective actions from reports

and confirm their implementation through

observation.

Examples

Emergency Preparedness

Incident Management

Additional Items - Random Observations


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ALBERTA GOVERNMENT OCCUPATIONAL HEALTH AND · PDF fileOCCUPATIONAL HEALTH AND SAFETY: AUDIT...

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