AS/NZS 4801

OHSAS 18001
OHS20309
SAI Global

OHS AUDIT PROCEDURE

March 2013

TABLE OF CONTENTS
1.

PURPOSE ............................................................................................................................. 2

2.

SCOPE .................................................................................................................................. 2

3.

ABBREVIATIONS ................................................................................................................. 2

4.

DEFINITIONS ........................................................................................................................ 2
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12

5.

SPECIFIC RESPONSIBILITIES ............................................................................................ 3

5.1
5.2
5.3

6.

COMPETENCY .................................................................................................................................................. 2
CONTROLLED ENTITY ........................................................................................................................................ 2
CORRECTIVE ACTION ........................................................................................................................................ 2
HEAD OF ACADEMIC/ADMINISTRATIVE UNIT OR CONTROLLED ENTITY ....................................................................... 2
NON CONFORMITY ............................................................................................................................................ 3
OHS AUDIT ...................................................................................................................................................... 3
OHS SELF-AUDIT .............................................................................................................................................. 3
OHS WORKPLACE SAFETY INSPECTION ................................................................................................................ 3
OHS INTERNAL AUDIT ........................................................................................................................................ 3
CERTIFICATION AND SURVEILLANCE AUDITS ......................................................................................................... 3
OHS AUDIT REPORT .......................................................................................................................................... 3
PREVENTATIVE ACTION ..................................................................................................................................... 3

MONASH OCCUPATIONAL HEALTH & SAFETY (OH&S) ............................................................................................. 4

OHS AUDITORS ................................................................................................................................................ 4
HEADS OF ACADEMIC/ADMINISTRATIVE UNITS OR CONTROLLED ENTITIES................................................................. 4

AUDIT.................................................................................................................................... 5
6.1
6.2
6.3
6.4

AUDIT PROGRAM .............................................................................................................................................. 5

AUDIT PROCEDURE OHS SELF AUDIT QUESTIONNAIRE ......................................................................................... 6
AUDIT PROCEDURE OHS WORKPLACE SAFETY INSPECTION ................................................................................. 6
AUDIT PROCEDURE OHS AUDIT; CERTIFICATION AND SURVEILLANCE AUDITS ......................................................... 7

7.

RECORDS ............................................................................................................................. 8

8.

TOOLS .................................................................................................................................. 9

9.

REFERENCES ...................................................................................................................... 9
9.1
9.2
9.3

10.

LEGISLATION ................................................................................................................................................... 9
MONASH UNIVERSITY OHS DOCUMENTS .............................................................................................................. 9
AUSTRALIAN STANDARDS .................................................................................................................................. 9

DOCUMENT HISTORY ......................................................................................................... 9

OHS audits at Monash University, v4

Date of first issue: June 2006

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

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Date of next review: 2016
17/01/13

1.

PURPOSE
This document sets out the procedure for implementing the OHS audit program at Monash
University as per the criteria of 4.5.5 with the standard OHSAS 18001:2007 Occupational
Health and Safety Systems - Requirements (criteria of 4.5.4 AS/NZS 4801:2001
Occupational Health & Safety Management Systems specifications with guidance for use)
and in accordance with the requirements of the Occupational Health and Safety Act (2004)
This procedure establishes the responsibilities, required competencies, and requirements for
planning and conducting audits, reporting results and retaining associated records; and the
determination of audit criteria, scope, frequency and methodology.

2.

SCOPE
This procedure applies to all occupational health and safety audits required to fulfill the
Monash University OHS management system requirements as outlined by OHSAS
18001:2007 criteria 4.5.5. This procedure does not apply to other audits that may be
conducted at Monash University such as Legal Compliance Audits.

3.

ABBREVIATIONS
OH&S
OHS
SDU

4.

Monash Occupational Health &Safety

Occupational health and safety
Staff Development Unit

DEFINITIONS
4.1

COMPETENCY

A person who has acquired through training, qualification, or experience, or a

combination of these, the knowledge and skills, including OHS knowledge and skills,
qualifying that person to perform the task required.
4.2

CONTROLLED ENTITY

Monash University controlled entities (e.g. companies) include entities where

Monash University can control decision making, directly or indirectly, in relation to
the financial and operating policies so as to enable the entity to operate with it in
pursuing the objectives of Monash University.
4.3

CORRECTIVE ACTION

Action taken to eliminate the cause of a detected nonconformity or other undesirable

situation.
4.4

HEAD OF ACADEMIC/ADMINISTRATIVE UNIT OR CONTROLLED ENTITY

Head of academic/administrative unit is used to denote the head of the area that is
undertaking the activity. For academic areas, this term includes head of faculty,
school, department, institute or centre. For administrative areas, the term includes
head of division, branch, centre, unit or controlled entity.

OHS audits at Monash University, v4

Date of first issue: June 2006

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

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Date of next review: 2016
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4.5

NON CONFORMITY

Non conformity is an activity or item that does not conform to the OHS policy,
relevant work standards, practices, procedures or legal requirements or any other
requirements of the Monash University OHS management system.
4.6

OHS AUDIT

An OHS audit is a systematic, independent and documented process for obtaining

evidence of the implementation of an OHS management system.
4.7

OHS SELF-AUDIT

A self-audit is an OHS audit conducted by an academic/administrative unit or

controlled entity.
4.8

OHS WORKPLACE SAFETY INSPECTION

An OHS workplace safety inspection is an OHS audit conducted by an

academic/administrative unit or controlled entity.
4.9

OHS INTERNAL AUDIT

An OHS internal audit is conducted by a lead auditor within any

academic/administrative unit or controlled entity. OHS internal audits include
specific University OHS procedures, relevant work standards, practices and legal
requirements.
4.10

CERTIFICATION AND SURVEILLANCE AUDITS

Certification and surveillance OHS audits are conducted by a certification body to

assess whether the Monash University OHS management system meets the
requirements of OHSAS 18001:2007 Occupational Health and Safety Systems
Requirements and AS/NZS 4801:2001 Occupational Health & Safety Management
Systems specifications with guidance for use.
4.11

OHS AUDIT REPORT

An OHS audit report is a documented report of audit findings.

4.12

PREVENTATIVE ACTION

Action to eliminate the cause of a potential nonconformity or other undesirable

potential situation

5.

SPECIFIC RESPONSIBILITIES
A comprehensive list of OHS responsibilities is provided in the document Occupational
health and safety management at Monash University: Structure, functions, roles and
responsibilities. The responsibilities of OHS audit participants are detailed within.

OHS audits at Monash University, v4

Date of first issue: June 2006

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

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Date of next review: 2016
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5.1

MONASH OCCUPATIONAL HEALTH & SAFETY (OH&S)

It is the responsibility of OH&S to:

coordinate the universitys OHS audit program;

distribute audit results;

maintain records of audit programs; and

Assist units/entities to develop and apply preventative and corrective actions

and controls to system or procedural deficiencies and non-conformances.

Follow up on the implementation of corrective and preventative actions

5.2

OHS AUDITORS

Auditors are responsible for the ensuring that audits are conducted in an impartial
and objective fashion. Auditors must be approved by OH&S.
5.2.1

Lead Auditors
Lead auditors must be appropriately trained and experienced.
Minimum competency requirements have been set as:

Participation in at least one audit as an auditor within the

previous 3 years;

Competent and certified to OHSAS19011;

OHS Lead auditor training as approved by OH&S;

Technical understanding of the risks associated with activities;

being conducted in the academic/administrative or controlled
entity being audited.

5.2.2

External Lead Auditors

External Lead auditors must be appropriately trained and experienced.
Minimum competency requirements have been set as:

Experience auditing against OHSAS18001;

Competent and certified to OHSAS19011;

OHS Auditor training as approved by OH&S.

5.2.3

Auditors
Auditors must be appropriately trained and experienced.
Minimum competency requirements have been set as:

Participation in at least one audit as an observer prior to

participating in an OHS audit;

Competent and certified to OHSAS19011;

OHS Auditor training as approved by OH&S;

Technical understanding of the risks associated with activities;

being conducted in the academic/administrative or controlled
entity being audited.

5.3

HEADS OF ACADEMIC/ADMINISTRATIVE UNITS OR CONTROLLED ENTITIES

It is the responsibility of the heads of academic/administrative units or controlled

entities to:

ensure self-audits are conducted annually and that preventative and corrective
actions are implemented;

ensure that workplace inspections are conducted at least biannually and that
preventative and corrective actions are implemented;

OHS audits at Monash University, v4

Date of first issue: June 2006

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

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Date of next review: 2016
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provide the lead auditor with evidence of current system and procedural
practices in response to audit questions;
communicate audit results to the local OHS committee/s; and
review the efficacy of preventive and corrective actions implemented.

6.

AUDIT
6.1

AUDIT PROGRAM

6.1.1

Audits will be conducted to:

OHS audits at Monash University shall be conducted in a systematic,
independent and documented method to obtain evidence of the
implementation of Monash Universitys OHS management system
within each respective academic/administrative unit or controlled
entity. The results of these audits shall be evaluated to objectively
determine non-conformity between current practices and the OHS
management systems requirements including but not limited to the
OHS policy, relevant work standards, practices, procedures or legal
requirements or any other requirements of the Monash University
OHS management system.

6.1.2

OHS audit program

6.1.2.1 An audit program will be prepared and maintained by OH&S. The
audit schedule will be available at the OH&S web site
(http://www.monash.edu.au/ohs/management-system/).
6.1.2.2 The audit schedule will reflect:

the level of risk associated with the activities conducted by

the academic/administrative unit or controlled entity;

the results of previous audits.

6.1.2.3 The audit procedures are broken down by type of audit (OHS selfaudit questionnaire, the workplace inspections, and OHS audits)
and the steps of the Monash University OHS management system
(planning, implementation, checking, and management review).
Further details of the Monash University OHS management
system can be found in the OHS Management system
implementation procedure.

6.1.3

Frequency of OHS audits

Audit Type:
Conducted by:
Frequency:
OHS
Self-audit Safety Officer and Head of Annually
questionnaire
each unit/entity
OHS
Workplace
safety inspection
Internal OHS Audit
Certification/
Surveillance Audit

OHS audits at Monash University, v4

Date of first issue: June 2006

Safety Officer and Head of Bi-Annually

each unit/entity
OH&S staff
As required, using criteria in 6.1.2.2
External consultants
SAI Global definition 3 yearly with
assessments 12 monthly throughout
the certification period

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

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6.2

AUDIT PROCEDURE OHS SELF AUDIT QUESTIONNAIRE

Step
6.2.1

Action
OHS SELF AUDIT QUESTIONNAIRE - Planning
It is the responsibility of the Head of academic/administrative or controlled
entity to ensure that this document is completed annually.
The Manager, OH&S is responsible for notification to Head of
academic/administrative or controlled entity of the mandatory timeframes.

6.2.2

OHS SELF AUDIT QUESTIONNAIRE - Implementation

The Manager, OH&S is responsible for notification to Head of
academic/administrative or controlled entity of the mandatory requirement to
complete.
Head of academic/administrative or controlled entity to ensure that the OHS
self-audit questionnaire is completed and submitted to OH&S.
OH&S controls the content of the self-audit questionnaire template and Head
of academic/administrative or controlled entity must ensure the latest version
is utilized. The Monash University OHS self-audit questionnaire is available at
the OH&S web site.

6.2.3

OHS SELF AUDIT QUESTIONNAIRE - Evaluation (Checking)

Each academic/administrative unit or controlled entity is required to objectively
complete every section of the self-audit questionnaire that is relevant to the
activities conducted.
This document must be submitted to OH&S.

6.2.4

OHS SELF AUDIT QUESTIONNAIRE - Management Review

The Manager, OH&S is responsible for reporting on the completion of the Self
Audit questionnaire for each academic/administrative unit or controlled entity.

6.3

AUDIT PROCEDURE OHS WORKPLACE SAFETY INSPECTION

Step
6.3.1

Action
OHS WORKPLACE SAFETY INSPECTION - Planning
It is the responsibility of the Head of academic/administrative or controlled
entity to ensure that this document is completed biannually.
The Manager, OH&S, is responsible for notification to Head of
academic/administrative or controlled entity of the mandatory timeframes.

6.3.2

OHS WORKPLACE SAFETY INSPECTION - Implementation

The Manager, OH&S is responsible for notification to Head of
academic/administrative or controlled entity of the mandatory requirement to
complete.
Head of academic/administrative or controlled entity to ensure that the OHS
workplace safety inspections are completed and submitted to OH&S.
OH&S controls the reportable elements of the workplace safety inspection and
Head of academic/administrative or controlled entity must ensure the latest
version is utilized. The Monash University OHS workplace safety inspection
template is available at the OH&S web site.

6.3.3

OHS WORKPLACE SAFETY INSPECTION - Evaluation (Checking)

Each academic/administrative unit or controlled entity is required to objectively
complete every section of the workplace safety inspection that is relevant to

OHS audits at Monash University, v4

Date of first issue: June 2006

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

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Date of next review: 2016
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Step

Action
the activities conducted.
The summary form must be submitted to OH&S

6.3.4

OHS WORKPLACE SAFETY INSPECTION - Management Review

The Manager, OH&S is responsible for reporting on the completion of the
workplace safety inspections for each academic/administrative unit or
controlled entity.

6.4

AUDIT PROCEDURE OHS AUDIT; CERTIFICATION AND SURVEILLANCE AUDITS

Step
6.4.1

Action
OHS Audit - Planning
The Manager, OH&S is responsible for nomination and notification of
scheduled audits to academic/administrative or controlled entity.
Notification will be sent to the following roles (where relevant);
o Head of academic/administrative unit or controlled entity;
o Safety officer;
o Specialty role officer/s;
o Health safety representative;
o Academic/administrative or controlled entity Managers;
o Faculty/divisional Manager;
o Dean of faculty; and
o OHS consultant/advisor of the area.
Audits may be conducted at any time without notification based upon:
o Previous audit results;
o Regulatory inspections/entry reports;
o Operational changes;
o Management reviews;
o Hazards or incidents; or
o Identified non-conformance.

6.4.2

OHS Audit - Implementation

Head of academic/administrative or controlled entity must ensure participation
in all OHS audits of their units.
The Lead Auditor is responsible for:
o Collating relevant information for review by the audit team which may
include operating procedures, previous audit findings, standards, legal
requirements, internal procedures;
o Conducting OHS audit opening meeting with relevant parties within an
academic/administrative unit or controlled entity to ascertain the
activities currently conducted and determine what will be included;
o Communicating the reporting procedure to be followed;
Where external auditors may be involved, the external lead auditor may be
invited to attend opening meetings
The Manager, OH&S is responsible for ensuring that appropriate resources
(e.g. audit packages, external consultant/auditor, training or other specialist
material) are made available to conduct effective audits. An audit may be
postponed if resourcing is deemed to be impracticable.

6.4.3

OHS Audit Evaluation (Checking)

Lead Auditor is required to conduct, using a documented method, a
systematic and independent evaluation of the implementation of Monash

OHS audits at Monash University, v4

Date of first issue: June 2006

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

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7.

Step

Action
Universitys OHS management system.
Each respective academic/administrative unit or controlled entity must be
individually evaluated.
Where external auditors may be involved, an external lead auditor is
responsible for completing the evaluation.
A report summarizing the OHS audit findings must be compiled and the report
provided to OH&S within 4 weeks.

6.4.4

OHS Audit - Management Review

The Lead Auditor will conduct a closing meeting to discuss the audit findings
and to jointly develop a set of agreed preventive and corrective actions
Head of academic/administrative units or controlled entities are responsible
for ensuring that preventative and corrective actions are implemented.
The Manager, OH&S, is responsible for reporting on the completion of the
workplace safety inspections for each academic/administrative unit or
controlled entity.

RECORDS

Records to be kept by

Records

To be kept for

Academic/Administrative
unit/controlled entity

Records of audits including:

7 years

OH&S

OHS audits at Monash University, v4

Date of first issue: June 2006

self-audits

internal OHS audits

external OHS audits

certification and surveillance

audits

Records of Workplace Inspections

10 Years

Records of audits including:

10 years

self-audits

workplace inspections

internal OHS audits

external OHS audits

certification and surveillance

audits

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

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8.

TOOLS

Monash University OHS self-audit questionnaire

Monash University OHS workplace safety inspection template (proforma)

9.

REFERENCES
9.1

LEGISLATION

Occupational Health and Safety Act 2004 (Vic)

Occupational Health and Safety Regulations 2007 (Vic)
9.2

9.3

MONASH UNIVERSITY OHS DOCUMENTS

Monash University OHS Self audit questionnaires
OHS management system implementation procedure
OHS structure, functions, roles and responsibilities procedure
OHS Records management
AUSTRALIAN STANDARDS
AS/NZS 4801:2001 Occupational Health & Safety Management Systems
specifications with guidance for use.
OHSAS 18001:2007 Occupational Health & Safety Management Systems
requirements
OHSAS 19011:2002 Guidelines for quality and/or environmental management
systems auditing

10. DOCUMENT HISTORY

Version
number
3
4

Date of Issue

Changes made to document

February 2011
February 2013

OHS Audits at Monash

Title change OHS Audit Procedure
Added definitions to ensure all are included that are referenced
Added workplace safety inspections as type of audit
Type of Audit - Internal and External audits merged, now called
OHS Audits.
Added Lead Auditor to responsibilities section
Updated procedures to reflect 18001 sequence of audits
Added workplace safety inspection procedure`
Procedure for OHS Audits updated to reflect new types of audit.
Added Standards to references
Added workplace safety inspection as tool.

OHS audits at Monash University, v4

Date of first issue: June 2006

Responsible Officer: Manager, OH&S

Date of last review: March 2013
For the latest version of this document please go to: http://www.monash.edu.au/ohs/

Page 9 of 9
Date of next review: 2016
17/01/13