1.1 The aim of this procedure is to provide instructions for the creation, management and distribution of controlled documentation, which forms part of a University Occupational Health and Safety (OHS) Management System.
Control of Management System Documentation
2.1 This procedure details the requirements to follow when creating, editing or distributing documents or records that are considered to be ‘controlled documentation’ forming part of the University OHS Management System - see definitions in Section 3 below.
2.2 The procedure outlines how to:
a) Approve controlled documentation for adequacy prior to issue, including such documentation of external origin that is of relevance.
b) Review, update as necessary and re-approve controlled documentation.
c) Ensure that changes and the current revision status of controlled documentation are identified.
d) Ensure that relevant versions of controlled documentation are available at point- of-use and retained for specified timeframes.
e) Ensure that controlled documentation remain legible and readily identifiable.
f) Identify obsolete controlled documentation to prevent its unintended use.
g) Archive applicable controlled documentation for specified timeframes.
2.3 For the purposes of the University OHS Management System, ‘controlled documentation’ is considered to be:
a) University Health and Safety Policy.
b) University Occupational Health Policy.
c) University Health and Safety Management System Manual.
d) Associated University Arrangements, Policies, Procedures and Forms.
3.1 Controlled Documentation: A document or record considered to be part of the University OHS Management System for which distribution and status are required to be kept current by the issuer to ensure that authorised holders or users have the most up-to-date version available.
3.2 Policy: Focused on a specific topic, an individual policy will outline the University aims and actions along with establishing mandatory requirements that individuals must follow.
3.3 Procedure: A fixed, specified process to follow in order to correctly perform a task or achieve a consistent outcome. A procedure may outline a step-by-step sequence of activities or course of action (with definite start and end points) and can be written or verbally agreed.
3.4 Arrangements: Written measures which may refer to a number of different policies and procedures. Applicable policies or procedures to be followed will vary depending on specific situations or criteria which are met, as described in the arrangements.
3.5 Best Practice Guidelines: A set of best practice principles that may be followed. They may be developed internally or issued by an external body, Regulator or professional association.
3.6 Health and Safety Management System: A structured system used to identify, manage and reduce the University’s health and safety risks and implement its Health and Safety Policy.
4.1 The University Corporate Identity guidelines should be referenced for the latest guidance on font and styling to use when creating new controlled documentation.
4.2 It is preferable that controlled documentation should be created and edited electronically using suitable methods to aid consultation and engagement such as sharing access.
4.3 The electronic file name of controlled documentation should contain the document name, the current issue date and the version number.
4.4 As a minimum, the recurring details on each page of a controlled document or record should include the documentation name, version number, the current page number and the total number of pages. These minimum control elements should be consistently placed on each page, normally in the header/footer, as per this procedure.
4.5 When developing procedures or arrangements, each section heading and subsequent paragraphs should be numbered, as per this procedure layout. It is required to number individual paragraphs in controlled policies, forms and registers and for flow charts. Where flow charts summarise details within a policy or procedure, it is suggested they are located in an Appendix to the main body of the document.
5.1 Specific information must be included within individual controlled documentation to identify the version and approval requirements.
5.2 For new documents the document number will be issued by the OHS Department taking the next available number from a spreadsheet stored on the Health and Safety shared drive.
5.3 A version control table should be completed at the end of the document or record as shown in the example below:
Document control
| Document title | Occupational Health and Safety Policy Statement |
|---|---|
| Document number | OB-OHS-POL-1.00 |
| Version number | V2.0 |
| Originator name/document owner | Paul Bradley |
| Directorate/Department | Occupational Health and Safety Department |
| Date of Last Review | DD-MON-YYYY |
| Date of this version | DD-MON-YYYY |
| Date of next review | MON-YYYY |
| Approved At / By | |
| Date of Approval |
5.4 Forms do not require the inclusion of a version control table in the individual document, rather the version control information should be detailed within the relevant OHS Management System Register of Controlled Documentation.
5.5 Decimal increments should be used for version control so that a distinction can be made between major and minor changes. Once the documentation has moved to a final version, the version numbers should begin, so the first final version should be 1.0. Any minor revisions made after this would then be 1.1, 1.2 etc. The second final version would be version 2.0 and so on.
6.1 Controlled documentation must be reviewed on a regular basis by the document owner (identified as the Person responsible in the version control table) to ensure continuing adequacy and relevance. The review period will be determined by the document owner, but not exceeding a period of three years or sooner as needed e.g. as a result of an audit finding, or change of legislation.
6.2 The review will include the necessary consultation with a range of stakeholders (including union appointed safety representatives). This will be through sharing the document via Google Docs. Policies and Procedures will be made available for comment for a maximum of two weeks.
6.3 Suggestions from the consultation process may not always be included within the revised document but rationale will be provided.
6.4 If the review of a controlled document or record does not identify any required changes, the version number may remain the same, and the review date amended as necessary.
6.5 Minor changes should be concisely detailed in an ‘amendments log’, which should be located at the end of the controlled documentation beneath the Version Control table.
6.6 During the review process a watermark may also be applied to electronic controlled documentation with the wording ‘DRAFT FOR REVIEW’ displayed diagonally across the page.
6.7 Once required amendments have been made, the draft version should be submitted to the appropriate nominated individual, Working Group, Board, Committee or University Executive for review and approval as outlined in the table below:
| Approval of minor amendments by: | Director of Occupational Health and Safety |
|---|---|
| Approval of new/major amendments documentation by: | Through existing committee structure |
6.8 It is the responsibility of the appropriate individual or entity to review and authorise approval of controlled documentation in a timely manner.
6.9 Approval of new or amended controlled documentation by a University Working Group, Committee, Board or the University Executive should be recorded in the corresponding meeting minutes.
6.10 Approval of minor amendments to controlled documentation by the appropriate University Manager should also be recorded. This should be in the form of an email to the Person responsible, as identified in the Version Control table.
6.11 Once the draft version of a major change has been approved the Person responsible should:
a) Increase the version number by '1'
b) Amend the page watermark on electronic documentation to read ‘UNCONTROLLED WHEN PRINTED’.
c) Clear the ‘Amendments Log’ in the documentation to re-set the record of amendments to coincide with the new version.
d) Update the ‘approval date’ and version control table accordingly.
e) Save the approved controlled documentation as a new version for distribution.
6.12 For OHS controlled documentation, approval via confirmatory email is acceptable and the following table should be included beneath the Version Control table on all such documentation.
Signature
| Name | Brendan Casey |
|---|---|
| Title | Chair of OB University Health, Safety and Welfare Strategic Committee (HSWSC) |
6.13 In the signature field the date of receipt of the approval email should be given as should the location of where the email is saved within the OHS electronic filing system.
8.1 When a controlled document becomes obsolete, it must be withdrawn from all distribution locations and identified as obsolete. The same process is required to remove an old issue of newly updated controlled documentation.
8.2 The title of withdrawn controlled documentation should be re-named to include the word ‘OBSOLETE’. If the documentation also contains a page watermark this should be amended to read ‘OBSOLETE’.
8.3 Obsolete documents must not be automatically deleted but managed in accordance with the OHS record retention schedule.
9.1 Controlled documentation that forms part of the University OHS Management System must be retained in line with the OHS record retention schedule. Where a document is not explicitly referenced in the schedule and a retention period is not prescribed in legislation, the document should be retained for seven years.
9.2 Hard copy documents which have reached the end of their retention period should be destroyed by shredding.