To establish a process to control all UON Health and Safety Management System Framework

Transcription

1 UON Health and Safety Procedure: HSP 9.1 Records, Documents and Document Control 1. Purpose To establish a process to control all UON Health and Safety Management System Framework policies, elements, procedures, guidelines and related records and to also document the process for initiating and making changes to these documents. 2. Scope This document applies to all Faculties, Divisions and organisational units of the University of Newcastle and its controlled entities. 3. Definitions In the context of this document, the following definitions apply: UON Health and Safety Management System Framework (UON HSMSF): The Framework which outlines the Health and Safety Management System for the University comprising policy, elements, procedures and guidelines documentation. Records: Information and data relating to persons, plant and equipment, facilities, processes and procedures relevant to health and safety (H&S) at the University (Refer section 6.2 of this procedure) Leaders/Supervisors: Any member of the University who is responsible for supervising staff and/or undergraduate or postgraduate students and/or for leading research projects. Workers: : As defined in the NSW Work Health & Safety (WHS) Act 2011, workers include employees, conjoints, students on work experience, contractors, subcontractors and their employees. Staff, conjoints, students on work experience, and contractors may be referred to collectively as workers, or separately as staff, conjoints, students, or contractors. Local Safety Contact Person: An employee within an organisational unit that has been allocated a role to act as a knowledge, communication, and support point for the organisational unit with regards to H&S. Document Change Request (DCR): means any request for change to an existing H&S Management Systems Framework document whether written or verbal. Uncontrolled when printed Page 1 of 10

2 4. Responsibilities 4.1 Vice-Chancellor and Executive Committee Monitor that processes are implemented to maintain records in line with the requirements of the NSW WHS legislation. Ensure that sufficient resources are provided to support the processes relating to document and record management, control and storage. 4.2 Health and Safety Team Review the UON Health and Safety Management System Framework (UON HSMSF) documentation 3 yearly as a minimum to ensure continuing compliance with legislative requirements and their relevance to the University; Identify and draft additional documents when the need arises as a result of legislative or business changes; Arrange for employees to be consulted on revisions and new documents prior to authorisation, via the University, Faculty and Division H&S Committees; Notify Leaders and Local Safety Contact Persons of updates to H&S Management System Framework documentation; Assist Leaders and Local Safety Contact Persons to identify the H&S records that they are required to keep to support their area s H&S management system. 4.3 University, Faculty and Division Health and Safety Committees Assist with the review process of all UON HSMSF documentation. 4.4 Leaders/Supervisors Monitor the appropriate application of H&S procedures and processes; Assist with the review process of all UON HSMSF documentation where appropriate; Maintain H&S records as required to support the H&S management system in their area of responsibility and comply with record retention requirements. Uncontrolled when printed Page 2 of 10

3 5. Procedure Document Management and Control 5.1 General requirements The Health and Safety Team will maintain the UON HSMSF documentation located on the Health and Safety Management System Framework page. All documents are considered to be controlled. The Associate Director, Health and Safety will endorse and maintain all UON HSMSF documents including all updates and changes. Revisions to the UON HSMSF Documents will be processed in the same manner as originals and subjected to the same level of review and approval before issue: Policy documents require final approval by the Vice-Chancellor and/or Executive Committee; Elements and Procedures documents require approval by the Director, People & Workforce Strategy, Human Resource Services; Guidelines documents require approval by the Associate Director, Health and Safety. All UON HSMSF Documents will be formatted in accordance with the templates which are controlled by the Associate Director, Health and Safety and administered by the Health and Safety Team. Referenced documents will be attached to the relevant procedure or included as website hyperlinks. Document versions will be tracked with the version number recorded in the footer as a whole number and the date of the versions e.g. v All CONTROLLED copies of the UON HSMSF Documents will be maintained as current versions on the UON Health and Safety Website. Once printed a procedure or document is to be considered UNCONTROLLED and is not to be relied upon as source material. 5.2 Document change Review of the documents and requests for changes will be processed by a member of the H&S Team within Human Resource Services. Changes to Controlled procedure document(s) will only be made by the Associate Director, Health and Safety or by a member of the H&S Team following approval by the Associate Director, Health and Safety. Uncontrolled when printed Page 3 of 10

4 To request changes to documents in the H&S Management System a Document Change Request (DCR) may be raised by any UON employee. 5.3 Raising Document Change Requests (DCRs) Prior to raising a DCR the initiator should liaise with other relevant personnel in order to obtain verbal agreement or endorsement e.g. Area Leader / Supervisor or H&S Committee member. If the need for a change or new document is established, the initiator should raise a DCR with a member of the Health and Safety Team. A Document Change Request Form can be used for this purpose (see Attachment 1). Upon receipt of a DCR the H&S Team will: Document the relevant details of a verbal request when received; Review the DCR and, if agreeable, endorse the request; Consider if requested changes are likely to impact on training requirements; Draft an updated copy of the affected document; Forward a draft copy of the revised document to the initiator for review. The initiator will be requested to: Review the revised document(s); If acceptable return the revised document(s) to the H&S Team. If the revised document(s) require further changes or amendments, the H&S Team will not release the document until it is agreed with the initiator. The H&S Team member dealing with the DCR will provide details of the DCR to the Associate Director, Health and Safety. The Associate Director, Health and Safety will, if agreeable, endorse the proposed changes. If the request for change is not accepted, feedback must be provided to the initiator with an explanation as to why the request has not been accepted. 5.4 Consultation Revised and new documents will be submitted to University H&S Committees for consultation and an opportunity to suggest edits. Following the consultation process the H&S Team will finalise the draft. Uncontrolled when printed Page 4 of 10

5 5.5 Obtaining authorised approval to make the change When the draft document has been finalised the Associate Director, Health and Safety will present the revised or new documents to the Director, People & Workforce Strategy, Human Resource Services for review and authorisation. Policy documents requiring final approval by the Vice-Chancellor and/or Executive Committee, will be sought following review by The Director, People & Workforce Strategy, Human Resource Services. 5.6 Implementation and communication of revised or new documents The Associate Director, Health and Safety is responsible for: Removing the superseded document from the UON Health and Safety Website and posting the new CONTROLLED DOCUMENT ; Communicating the posting of the revised document to area Leaders and H&S Committees. 5.7 Document audits Audits of the UON HSMSF Documents will be conducted during internal and external audits. This will include both University-wide and area specific documents and nonconformances found during the audits will result in corrective actions which will be implemented by the relevant area and monitored for closure by the Associate Director, Health and Safety and the H&S Team. 6. Procedure Health and Safety records management Leaders have the responsibility to ensure appropriate H&S records are maintained by making reference to this procedure to determine what records are required to be kept, how these records should be kept, the time period they need to be maintained, and how the records can be accessed so that confidentiality requirements are adhered to. 6.1 Maintenance of records Processes for maintaining health and safety records should take into account: Responsibility: who will be responsible for ensuring that the document is kept; Accessibility: who will have access to the documents; Storage: where documents will be stored and the level of access control; Disposal: length of period the document will be kept before disposal. See Attachment 2 for a table of Regulatory Document Record Retention. 6.2 Examples of records to be maintained Uncontrolled when printed Page 5 of 10

6 Employee qualifications, skills, knowledge, competency and certifications; Induction and training; Inspection and test reports; Audit reports; Internal management system reviews; Minutes of management review meetings; Incident reports/accident reports and investigations; Minutes of Health and Safety Committee meetings, including Faculty, Division and School meetings relating to health and safety; Statistical analysis of health and safety data; Health and Safety action plans; Safety equipment records and records of equipment maintenance; Hazardous substances and dangerous goods inventories and chemical Safety Data Sheets (SDS); Design reviews and approvals; Risk management documentation e.g. Hazard Registers, risk assessments; Records relating to contractors safety management and their compliance with health and safety requirements e.g. pre-qualification questionnaires, induction, Job Safety Analysis (JSAs) for the work, permits to work, monitoring of H&S compliance; Records associated with supplier compliance including suppliers of goods, services and labour hire. 7. References UON Health and Safety Management System Framework 8. Attachments Attachment 1: Document Change Request Form Attachment 2: Document Regulatory Record Retention Table Uncontrolled when printed Page 6 of 10

7 Document Summary Table Records, Documents, and Document Control HSP 9.1 Date of first edition: 31/3/15 Date this N/A Date of 31/3/18 review will next take effect: Review: RM Folder Ref: <completio Document HSP 9.1 v1 Revision <completion n by policy Number: Number: by H&S team> Team> Approved by: Owner: Contact: Governing Legislation: Director, People and Workforce Strategy Associate Director, Health and Safety University of Newcastle Health and Safety Team NSW Work Health and Safety Act and Regulations 2011 Supporting documents & forms of this procedure/guideline: Keywords: UON H&S Management System Framework Document Change Request Form Document Regulatory Record Retention Table Health and Safety; H&S; Records; Documentation; Document Control. Important Notes: Revision History / Version Control 1 st version of the document Uncontrolled when printed Page 7 of 10

8 Attachment 1: Document Change Request Form Document Change Request (DCR) Form UON HSMSF Documents Name of Document: Description of Change requested: Reason for Change: Name of person requesting change: Area: Contact Telephone number: Date: Consultation (detail endorsement received from relevant personnel e.g. Area Leader). Health and Safety Team: Name of person making change: Date: Approval: Associate Director Health and Safety Y / N Date: Date Draft Version sent to initiator: Date Draft forwarded to Health and Safety Committee/s: Date forwarded to Director, PAWS,HRS for approval: Date Approved Version uploaded on the Source : Date: Date: Uncontrolled when printed Page 8 of 10

9 Attachment 2: Document Regulatory Record Retention Table Medical records DOCUMENT REGULATORY RECORD RETENTION TABLE RECORD RESPONSIBILITY ACCESSIBILITY LOCATION STORAGE DISPOSAL Audiometric Test Results Noise Assessments Asbestos Assessments Plant Register & Registration Certificates. Relevant Area Leader &/or HRS Relevant Area Leader &/or HRS Relevant Area Leader &/or HRS Services (IFS) Services (IFS) Confidential / Employee UON Health Service restricted Duration of Employment plus Thirty years Confidential / Employee Relevant Area & UON Health Service restricted Duration of Employment plus Thirty years Employees & H&S Team At Work Area restricted Duration of Employment plus Thirty years Employees & H&S Team At Work Area open Thirty years Employees & H&S Team At Work Area open As long as the certificate is relevant Plant Risk Assessments Relevant Area Leader Employees & H&S Team At Work Area open Minimum of 5 years Incident Records Notice of Incidents & Notices of Dangerous Occurrences Manual Handling Risk Assessments. Hazard reports Injured person, Area Leader, H&S Committee. Employees & H&S Team At Work Area restricted Minimum of seven years At Work Area & H&S restricted Minimum of seven years Relevant Area Manager Employees & H&S Team At Work Area open Minimum of 5 years Employees & H&S Team At Work Area & H&S open Minimum of 5 years Workplace safety inspection reports Employees & H&S Team At Work Area open Minimum of 5 years Other risk assessment reports Relevant Area Leader Employees & H&S Team At Work Area open Minimum of 5 years Uncontrolled when printed Page 9 of 10

10 RECORD RESPONSIBILITY ACCESSIBILITY LOCATION STORAGE DISPOSAL Dangerous Goods Manifest Services (IFS) or relevant Area Leader Employees & H&S Team, local Emergency Fire service At Work Area open As long as information is current Dangerous Goods Risk Assessment Documentation. Relevant Area Leader Employees & H&S Team At Work Area open Minimum of 5 years Dangerous Goods Licence Services (IFS) or relevant Area Leader Employees & H&S Team, local Emergency Fire service At Work Area open As long as licence is current Dangerous Goods Emergency Plans Services (IFS) or relevant Area Leader Employees & H&S Team, local Emergency Fire service At Work Area open As long as information is current Dangerous Goods Incident Reports. Employees & H&S Team At Work Area restricted Minimum of 7 years Emergency equipment and Fire protection equipment inspection and Maintenance Reports. Services (IFS) or relevant Area Leader Employees & H&S Team At Work Area open As long as equipment remains in service. Hazardous substances Register Relevant Area Leader Employees & H&S Team At Work Area open As long as information is current Material Safety Data Sheets Relevant Area Leader Employees & H&S Team At Work Area open As long as information is current Dangerous Goods CFA/ MFB Recommendation Reports Notices and Written Directives from inspectors Relevant Area Leader Employees & H&S Team At Work Area restricted As long as information is current Employees & H&S Team At Work Area restricted Minimum of 7 years Workers Compensation Records H&S Confidential / Employee H&S restricted To be maintained in perpetuity Rehabilitation case notes H&S Confidential / Employee H&S restricted To be maintained in perpetuity Workplace Environmental reports Relevant Area Leader Employees & H&S Team At Work Area open Thirty years H&S Committee minutes Employees & H&S Team At Work Area open Minimum of 5 years Training Register Relevant Area Leader Employees & H&S Team At Work Area restricted Duration of Employment plus Five years Training Matrix (Inc. employee licences & certificates ) Relevant Area Leader Employees & H&S Team At Work Area restricted Duration of Employment plus five years Uncontrolled when printed Page 10 of 10