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2017
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 1
Table of Contents
If you have any questions or require any further information regarding this audit please email
vicschools.whs@au.ey.com or alternatively contact Milena Savanovic, at EY on 1800 004 747.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 2
Context and Objective of this Guide
The Department of Education and Training (DET) commenced implementation of an Occupational Health
and Safety Management System (OHSMS) in 2009. Since this time DET has strived to continuously improve
and test the effective implementation of its OHSMS within schools and workplaces.
To support its commitment to continuous improvement and monitoring, DET is looking to carry out Site Level
Occupational Health and Safety (OHS) audits to test the implementation of the Department’s OHSMS.
Although the audits will assess the majority of the OHSMS, the process will focus on how schools and
workplaces are managing OHS risks and hazards.
This guide provides schools and workplaces with relevant information to prepare for the audit process
including the audit approach and audit criteria. An auditor will work closely with you during the process to
discuss potential findings and observations. Once the audit is completed you will receive an audit report
through a Web Portal including a set of actionable recommendations to assist you in improving safety
performance.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 3
Audit Process – From Initial Contact to Next Steps!
Figure 1 describes the audit process from the initial contact with schools and workplaces up to the review of the actions taken to close the gaps.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 4
Audit Structure
The structure of the audit has been designed to ensure all relevant elements of the OHSMS are effectively
assessed within the defined timeframe. For this a physical space to conduct meetings and interviews will be
required (e.g. office, desk or general working area) as well as access to OHS documents, IT systems and
key stakeholders.
Table 1 shows the suggested structure and timeframes of the full day audit. Information is also provided on
the relevant people to be interviewed during the audit, including the following key employees:
Workplace Manager (i.e. Principal)
Management OHS Nominee
Health and Safety Representative
First Aid Officer
Business Manager
Chief Warden
It is important that you allocate a responsible person to receive the auditor to support the audit process. This
person must be the Management OHS Nominee, the Principal or Workplace Manager as applicable.
A comprehensive table listing the audit criteria, possible documented evidence and suggested key
stakeholders that may be interviewed during the audit is provided in Table 2. Using this table, you will be
able to prepare for the audit effectively.
Please note that the audit is structured in order to test key elements of the OHSMS first. However, this
approach may vary depending on the auditor’s findings or the type of school or workplace being audited.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 5
# Aspects to be Assessed Relevant Stakeholders Allocated Time
Consultation OHS Nominee
3.3 Risk and Hazards Management Workplace Manager, HSR, Management
75 mins
OHS Nominee
Lunch Break
3.4 Incident Reporting and Workplace Manager, HSR, Management
30 mins
Investigation OHS Nominee
4.1 Emergency Management Workplace Manager, HSR, Management
OHS Nominee, Chief Wardens 30 mins
4.2 First Aid First aid officers
5 Training and Induction Workplace Manager, HSR, Management
30 mins
OHS Nominee
6.1 Contractor Management Workplace Manager, HSR, Management
OHS Nominee, Business Manager 30 mins
6.2 Purchasing Workplace Manager, HSR, Management
OHS Nominee, Business Manager
7 Audit Review Auditor time for reviewing documentation
and preparing the closing meeting.
60 mins
Key stakeholders involved during the audit
may be required.
8 Final Meeting Workplace Manager, HSR, Management
30 mins
OHS Nominee
Total Time 7.5 hrs
The audit comprises multiple criteria combined into nine elements of the Department’s OHSMS. The audit
tool has been developed from key aspects of the OHSMS that were considered to be relevant to schools and
workplaces.
The following pages define the audit criteria and provide further information about the criteria to assist
schools and workplaces with interpretation and understanding of the audit procedures. If this information is
used to prepare for the visit, the audit will be performed effectively, within the allocated timeframes and
accurately reflect the schools and workplaces performance in implementing the OHSMS.
The elements and criteria that will be assessed during the audit are described below.
A planned approach to OHS is a critical component of the implementation of the OHSMS. Schools and
workplaces need to plan for OHS activities. A generic OHS Activities Calendar has been developed by the
Department to ensure a planned and systematic approach to OHS is adopted.
Workplace health and safety benefits significantly from effective consultation with employees. Employees are
often best placed to identify health and safety hazards and issues in the workplace and therefore are
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 6
generally in the best position to suggest appropriate controls for those hazards. Effective consultation and
communication will assist in building commitment to health and safety across DET.
It is important that existing and potential OHS hazards and associated risks are identified and effectively
managed in DET schools and workplaces.
DET uses a risk management approach to manage hazards in the workplace. Risk management principles
allow for the identification, assessment, control and monitoring of OHS risks. The approach requires the
prioritisation of risks so adequate resources can be allocated to identify and implement required risk controls.
Schools and workplaces must understand their own particular OHS risk profile to identify and implement
appropriate procedures to control hazards and risks.
It is necessary to monitor the workplace conditions and gather information about potential hazards and to
have processes in place to act on the information obtained. Where accidents or incidents occur, it is crucial
that they are reported and an investigation is carried out to determine the underlying causes and implement
risk controls to prevent recurrence of the event.
The Department is committed to providing a safe and secure environment for all employees, contractors,
visitors and students. Every school and workplace in Victoria is required to have an Emergency
Management Plan (EMP).
It is important to identify first aid requirements and implement appropriate arrangements to ensure all injured
persons are provided with immediate and adequate treatment in the case of injury and/or illness at DET
schools or workplaces.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 7
DET workplaces differ in size and complexity. This will mean that first aid requirements will vary from one
workplace to another and therefore must be determined locally through a consultative risk assessment
process.
The adequacy of the provision of first aid in the school or workplace should be reviewed annually. The
school or workplace first aid needs may change if employee or student numbers change significantly.
OHS training is an integral part of an OHSMS and is necessary to ensure safe and effective implementation
of health and safety policies and procedures. Training is also an essential tool to establish an active,
preventative approach to OHS risk in the workplace.
It is important to understand that employers have the same duty of care towards contractors and volunteer
workers as they do to their employees. This means that a process must be implemented to ensure all
contractors volunteer workers engaged by a school or workplace work safely when on site and do not
introduce any unmanaged risks when undertaking the work they have been engaged to do.
Element 9: Purchasing
Health and safety hazards can be introduced into the school or workplace as a result of the purchase of
goods e.g. plant and equipment or chemicals. Prior to any purchase, hazards must be identified and
assessed. Where a hazard has been identified as a result of a proposed purchase, any new or additional
risks must be controlled when the item is delivered and/or stored in the workplace.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 8
Audit Guidance – Preparing for the Audit
This section aims to provide schools and workplaces with a better understanding of the elements of the
OHSMS that will be assessed during the audit. In preparation for the audit, we recommend schools and
workplaces follow this table, ensure the relevant personnel attend the audit interviews, and gather relevant
information that may be required by the auditor during the assessment.
Table 2 presents the elements of the Department’s OHSMS that will be assessed, as well as examples of
evidence that might be requested during the audit.
• OHS Activities
Calendar Template
• OHS Planning 6.2 Initial Review of Responsible persons and/or OHS Activities Calendar
Procedure (DEE the OHS Activities resources, and the frequency Names of responsible
ESWB-02-1-4) Calendar in which the identified OHS persons for the defined
activities will be implemented activities
• OHS Activities 6.3 Allocating is clearly specified in the
Calendar Template Responsibility for OHS Activities Calendar.
Activities
• OHS Planning 6.4 On-going Review The OHS Activities Calendar Updated OHS Activities
Procedure (DEE of the OHS Activities or equivalent is reviewed at Calendar
ESWB-02-1-4) Calendar least on a monthly basis or Meeting minutes
after relevant milestones or Emails
events have occurred. Records of activities being
Records demonstrate that performed
the activities identified in the
OHS Activities Calendar
have been implemented as
planned.
The OHS Activity Calendar is Updated OHS Activities
reviewed and completely Calendar
updated every 12 months. Meeting Minutes
Interviewees statements
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 9
Element 2: Consultation and Communication
OHSMS Procedure OHSMS Sections Audit Criteria Examples of Evidence
Name
• OHS 3.5 Health and An OHS Committee meeting OHS Activities Calendar
Responsibilities Safety Committee schedule has been OHS Noticeboard
Procedure (DET established (minimum
ESWB 03-3-5) quarterly) and is included in
the OHS Activities Calendar.
• OHS Committee Minutes of the meeting are
Guide (DET-ESWB- being recorded and
03-7-1) displayed on the OHS
Noticeboard.
• OHS Consultation 3.2.2 Health and Nominations for a Health and Emails, notifications
and Communication Safety Safety Representative (HSR) Newsletters
Procedure (DET Representatives have been called in the last
ESWB-03-2-6) (HSR) 12 months.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 10
Element 3: Risk and Hazard Management
OHSMS Procedure OHSMS Sections Audit Criteria Examples of Evidence
Name
ESWB-04-1-5)
• OHS Risk 6.3 Ongoing review The OHS Risk Register is Updated OHS Risk
Management of the OHS Risk reviewed and updated on an Register
Procedure (DEE Register annual basis or when OHS Activities Calendar
ESWB-04-1-5) required. Workplace Inspection
6.7 OHS Risk records
Register OHS Inspection checklist
• Workplace 6.1 Identifying areas Regular OHS inspections are OHS Inspection checklists
Inspection Procedure subject to Workplace undertaken for all relevant Signed workplace
(DEE ESWB-20-1-4) Inspection school or workplace areas Inspection records
using the OHS Inspection OHS Activities Calendar
6.6 Record Keeping Checklist. The results are
reviewed by the Workplace
Manager or Management
OHS Nominee to verify that
identified risks are being
adequately managed.
• OHS Risk 6.5 Guidance on the All relevant OHS hazards for OHS Risk Register
Management DET Risk the school or workplace have Hazards identification
Procedure (DEE Management been identified and listed in through site walkthrough
ESWB-04-1-5) Methodology the OHS Risk Register.
Control measures for the OHS Risk Register
OHS hazards identified in
the OHS Risk Register have
been defined following the
Hierarchy of Controls.
The residual risk level for the OHS Risk Register
OHS hazards identified in
the OHS Risk Register for
the workplace have been
assessed and the risk levels
are appropriate.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 11
Element 3.5: Hazards Management
OHSMS OHSMS Sections Audit Criteria Examples of Evidence may include
Procedure Name
Traffic Permit to Work
Risk assessments
Risk management forms
o Hazardous Manual Handling
o Plant and equipment
Hazardous Manual Handling Identification
Form (or equivalent template)
Plant and Equipment Maintenance Form
Workplace Inspection Checklists/Reports
Specific training records
Reports (Incident, IRIS, eduSafe)
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 12
Element 4: Incident Reporting and Investigation
OHSMS Procedure OHSMS Sections Audit Criteria Examples of Evidence
Name
• First Aid and
Infection Prevention
and Control
Procedure (DET
ESWB- 27-1-7)
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 13
Element 6: First Aid
OHSMS Procedure OHSMS Sections Audit Criteria Examples of Evidence
Name
ESWB-27-2-6)
• First Aid and 3.3.2 First Aid Kits School or workplace Site inspection and
Infection Prevention complies with at least the walkthrough
and Control minimum First Aid Officers, First Aid Officer list
Procedure (DET kits and rooms as described First Aid Kits Reviews
ESWB- 27-1-7) in the First Aid Risk First Aid Rooms
Assessment Form. inspections
• First Aid and 3.3 First Aid First aid rooms (when First Aid Rooms
Infection Prevention Rooms/Sick Bays applicable) are available and inspections
and Control comply with the minimum First Aid summary sheet
Procedure (DET 3.3.1 Minimum First first aid room requirements. Emergency management
ESWB- 27-1-7) Aid Room contact details
Requirements
• First Aid and 3.3 First Aid First aid area (sickbay) First Aid Areas
Infection Prevention Rooms/Sick Bays contains a first aid kit and First Aid summary sheet
and Control clearly displays the First Aid Emergency management
Procedure (DET 3.3.1 Minimum First Summary Sheet or contact details
ESWB- 27-1-7) Aid Room Emergency Management Site Inspection and
Requirements Contact details. walkthrough
• First Aid and 3.3 First Aid Regular inspections of first Completed First Aid Kits
Infection Prevention Rooms/Sick Bays aid facilities, including a Contents Checklist
and Control review of first aid kits are Inspection Records
Procedure (DET 3.3.2 First Aid Kits undertaken as planned or as OHS Activities Calendar
ESWB- 27-1-7) required.
• First Aid and 3.5 Infection and Infection control guidelines Interviews with First Aid
Infection Prevention Prevention Control are understood by Officers and/or
and Control responsible person(s) (e.g. responsible persons
Procedure (DET 3.6 Cleaning and First Aid Officer). Safe Work Procedure for
ESWB- 27-1-7) Sanitising Cleaning and Handling of
Blood and Body Fluids
3.7 Disposal of
Contaminated Waste
• First Aid and 3.2 First Aid Officer First Aid Officer(s) has Training records
Infection Prevention Training undertaken recognised first Training register
and Control aid training that meets the Training
Procedure (DET requirements of: diplomas/certificates
ESWB- 27-1-7) • Provide First Aid -
HLTAID003
• Annual refresher for
Cardiopulmonary
Resuscitation (CPR) -
HLTAID001.
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 14
Element 7: OHS Induction and Training
OHSMS Procedure OHSMS Sections Audit Criteria Examples of Evidence
Name
training requirements Signed OHS induction
• OHS Induction specified in the OHS forms
Checklist (DET Induction Checklist.
ESWB-24-5-7)
• OHS Induction and 3.4 Identify OHS Training Plan/Register OHS Training
Training Procedure Competencies and or equivalent template has Plan/Register
(DET ESWB 26-1-6) Schedule Training been developed and is kept OHS Training Matrix
into the OHS up to date with additional Job descriptions
Training Planner training needs included
where identified.
• OHS 3.1 Workplace OHS training has been Training records
Responsibilities Managers scheduled and/or completed OHS Training
Procedure (DET according to the OHS Plan/Register
ESWB 03-3-5) 3.2 Management Training Plan/Register or
OHS Nominees equivalent template.
Online OHS training Training records
mandatory for all employees Online records
has been completed, Training completion
including: certificates
• OHS for Employees-
Refresher
• Ergonomics-Refresher
• Manual Handling-Refresher
• Hazard and Incident
Reporting-Refresher
• Slips, Trips and Falls
Refresher
• DET Contractor
Register Template
• OHS Induction and 3.3 Contractor OHS An OHS induction process OHS Induction
Training Procedure Induction has been established for all documentation contractors
(DET ESWB 26-1-6) contractors that includes the content
information specified in the Contractor Induction
• Contractor OHS Contractor OHS Induction Checklist
Management requirements. OHS Induction Forms
Procedure (DET (Signed)
ESWB 24-1-4)
• Contractor OHS
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 15
Element 8: Contractor Management
OHSMS Procedure OHSMS Sections Audit Criteria Examples of Evidence
Name
Induction Checklist
(DET ESWB-24-2-5)
• Contractor OHS
Induction Handbook
(DET ESWB 24-6-1)
• Contractor OHS 3.4 Sign in / sign out All contractors report to the Sign in-out register
Management General Office upon arrival (Online or hard copy
Procedure (DET at the workplace, prior to register)
ESWB 24-1-4) commencing any works, and Available visitors passes
a visitor’s pass is issued.
• Contractor OHS 3.5 Provision of Safe A Safe Work Method Safe Work Method
Management Work Method Statement (SWMS) or Statements (SWMS)
Procedure (DET Statements for high equivalent is obtained from
ESWB 24-1-4) risk work contractors prior to
performing high risk activities
• Safe Work Method such as:
Statement Template • Hazardous manual
(DET ESWB-24-4-3) handling
• Operating mobile and/or
• Contractor Hazard powered equipment
Identification and • Use of concrete
Control Guide (DET • Working at heights
ESWB 24-5-4) • Use of hazardous
substances and dangerous
goods
• Working near electrical
lines or systems.
• Hot Work, and
• Removal or disturbance of
asbestos
• Contractor OHS 3.6 Confined Space A Permit to Work system is Confined Space Entry
Management Entry Permit established for contractors Permits
Procedure (DET working in Confined Spaces
ESWB 24-1-4) (where applicable).
• Confined Space
Entry Permit (DET
ESWB 24-4-4)
• Confined Space
Procedure (DET
ESWB-08-1-5)
• Volunteer Worker 3.2 Volunteer A risk assessment has been Risk assessments
OHS Management management risk completed for volunteer
Procedure (DET controls workers prior to them
ESWB-30-1-2) undertaking tasks such as:
• Gardening/landscaping
• Safe Work • Painting
Procedure (DEE • Clean-up of grounds
ESWB-05-2-3)
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 16
Element 8: Contractor Management
OHSMS Procedure OHSMS Sections Audit Criteria Examples of Evidence
Name
• Volunteer Worker 3.5 Volunteer worker An OHS induction process OHS Induction process for
OHS Management OHS Induction has been established for volunteer workers
Procedure (DET volunteer workers, which
ESWB-30-1-2) includes the information
specified in the Volunteer
• Volunteer Worker Worker OHS Induction
OHS Induction Checklist.
Checklist (DET
ESWB 30-2-2)
• Volunteer Worker
OHS Induction
Handbook (DET
ESWB 30-3-1)
Element 9: Purchasing
OHSMS Procedure OHSMS Sections Audit Criteria Examples of Evidence
Name
• OHS Purchasing 6.1 Identifying Goods An OHS Purchasing OHS Purchasing Checklist
Procedure (DEE with OHS Checklist is used to identify
ESWB-25-1-3) Implications goods with OHS
implications.
• OHS Purchasing
Checklist (DEE
ESWB-25-4-3)
• OHS Purchasing 6.2 Identifying Hazards and risk controls Completed OHS
Procedure (DEE specific OHS issues measures for all purchases Purchasing Checklist
ESWB-25-1-3) for purchased goods with OHS implications have
been adequately assessed
• OHS Purchasing and documented in the OHS
Checklist (DEE Purchasing Checklist.
ESWB-25-4-3)
• OHS Purchasing
Guidance (DEE
ESWB 25-3-3)
Department of Education and Training - Occupational Health and Safety Management System Audit Guidance 17