View
2
Download
0
Category
Preview:
Citation preview
COR™ 2020 Audit Handbook
COR2020HB July 2020
The Infrastructure Health & Safety Association (IHSA) is your new partner in preventing workplace injury and illness. We serve the transportation, electrical, utilities, construction, aggregates, pipelines, and ready-mix concrete industries.
IHSA was founded in January 2010 by amalgamating the Construction Safety Association of Ontario (CSAO), the Electrical & Utilities Safety Association of Ontario (E&USA) and the Transportation Health and Safety Association of Ontario (THSAO).
We are committed to providing you with world-class service and the information you need to prevent occupational injury and illness.
Disclaimer:
The contents contained in this publication are for general information only. This publication should not be regarded or relied upon as a definitive guide to government regulations or to safety practices and procedures. The contents of this publication were, to the best of our knowledge, current at the time of printing. However, no representations of any kind are made with regard to the accuracy, completeness or sufficiency of the contents. The appropriate regulations and statutes should be consulted. Readers should not act on the information contained herein without seeking specific independent legal advice on their specific circumstance. Infrastructure Health & Safety Association is pleased to answer individual requests for counseling and advice.
© Infrastructure Health & Safety Association 2010.
All rights reserved. This publication may not be reproduced, in whole or in part, or stored in any material form, without the express written permission of the copyright owner.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 2
COR™ 2020 Audi t Handbook
TABLE OF CONTENTS
INTRODUCTION ....................................................................................................................... 3
A. INSTRUCTIONS FOR COMPLETING COR™ 2020 .............................................................. 4
COR™ 2020 PROCESS ........................................................................................................ 5
1. Preparing for the Audit .................................................................................................... 5
General Audit Information ............................................................................................... 5
Audit Tool Format ........................................................................................................... 8
Verification Techniques .................................................................................................. 9
Scoring Legislated Requirements ..................................................................................10
Scoring ..........................................................................................................................10
Auditor’s Notes ..............................................................................................................12
2. Performing the Audit ......................................................................................................14
Document Review .........................................................................................................14
Interviews ......................................................................................................................16
Observations .................................................................................................................18
3. Summarizing the Audit ...................................................................................................19
Audit Summary Report ..................................................................................................19
Corrective Action Plan ...................................................................................................19
4. Submitting the Audit .......................................................................................................20
B. COR™ 2020 INTERNAL AUDIT EVIDENCE TIPS ...............................................................23
INTRODUCTION ..................................................................................................................23
AUDIT TIPS ..........................................................................................................................25
DEFINITIONS .......................................................................................................................50
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 3
COR™ 2020 Audi t Handbook
INTRODUCTION
This document has been made available by the Infrastructure Health and Safety Association
(IHSA). It is for the use of the Ontario COR™ 2020 registered organization’s internal auditors.
Senior Management Representatives must be familiar with the content and ensure the program
requirements are met and the Internal Auditor(s) have the support and resources they need.
The COR™ 2020 Audit Handbook has two sections:
A. Instructions for completing COR™ 2020 audit requirements
The purpose of this section is to provide internal auditors with:
Instructions on how to complete internal/maintenance audits from the pre-audit stage
to post-audit stage
Information regarding methods of verification (observation, documentation,
interviews)
Information on scoring methods
B. COR™ 2020 Internal audit evidence tips
The purpose of this section is to provide internal auditors with:
Tips and assistance in completing the COR™ 2020 Audit Tool efficiently and
effectively
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 4
COR™ 2020 Audi t Handbook
A. INSTRUCTIONS FOR COMPLETING COR™ 2020
Before you begin the COR™ 2020 audit process, here are a few things to consider or
verify:
All workplaces covered under your Workplace Safety & Insurance Board (WSIB)
account being considered for COR™ 2020 are included in the audit.
As the permanent full-time employee(s) assigned as Internal Auditor(s) for your
organization, you must have completed all pre-requisite training. Ensure IHSA is
informed if the internal auditor changes.
Have you reviewed the COR™ 2020 Program Guideline recently?
The COR™ 2020 Program Guideline is available on the IHSA Website at:
ihsa.ca/cor-home
Have you set aside a realistic amount of time to perform the audit?
The time to complete it will depend on the number of employees in your organization,
the scope of its work and the number of active projects or workplaces.
Have you reviewed the audit instructions to ensure you are familiar with the Audit
Tool and how to proceed?
Before applying for COR™ 2020, your organization must have a functioning occupational health
and safety management system (OHSMS) in place for at least one year and include the 14
elements required for the COR™ 2020 audit.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 5
COR™ 2020 Audi t Handbook
COR™ 2020 PROCESS
You can access an electronic copy of the COR™ 2020 audit package by visiting www.ihsa.ca/cor-
home and clicking on the e-file submission tool. Senior management must ensure that the
designated Internal Auditor completes the Audit Tool and supporting documents and forms
within the timeframes set out in the COR™ 2020 Program Guideline. There are three stages in
the COR™ 2020 audit process:
1. Preparing for the audit
2. Performing the audit
3. Summarizing the audit
1. Preparing for the Audit
General Audit Information
The audit requires review of documentation, observation of work in progress and interviews of
representatives of management and workers.
The time taken to complete an audit depends on the size and diversity of activities and locations
within your organization. Just considering the interview stage, each one will take approximately
30 minutes. If your audit requires 10 employees to be interviewed, the total interview time is 5
hours. Depending on where your employees are located and their availability, additional time
may be needed.
Preparation for audit includes:
Pre-audit preparation: The organization through the senior management representative
and the internal auditor must create an internal audit plan. The audit plan should be
communicated to the appropriate employees so they know what to expect when the
audit is carried out and what their responsibilities are.
Opening Meeting: The organization must hold a pre-audit meeting where the audit plan
is discussed. The organization must document the meeting by keeping minutes. The
date of the opening meeting must be recorded on the Audit Information Form that will be
submitted with your audit.
Project/workplace familiarization: The internal auditor must be familiar with the
organization and the workplaces to be audited.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 6
COR™ 2020 Audi t Handbook
Use the checklist below to help you ensure you have covered all the details for your pre-audit
steps.
COR™ 2020 Pre-Audit Checklist
1. Inform organization or participants of requirements Completed
Determine:
Name of organization key contact person
Date, time and location of the opening meeting
Date, time and location of document review (desk audit)
Names and positions of attendees for the pre-audit meeting
Locations of active worksites for the audit
Peak activity times
Organization activities on the day of the audit
Availability of H&S manual for advance review
Auditor personal protective equipment (PPE) required
Speciality PPE and training required
Additional auditor training (e.g. WHMIS, workplace specific)
Facility for interviews (quiet, comfortable, and convenient)
Availability of records/documentation for review
Workplace/site orientation requirements
Workplace/site escort requirements
Sample size and specifics for interviews
Number of management & workers available for interview
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 7
COR™ 2020 Audi t Handbook
2. Gather background information Completed
Locate: Written description of organization (website, annual report)
Organizational chart
Organization health and safety statistics
Previous audit or action plan (if available)
3. Gather tools
Obtain: COR™ Audit, interview and observation documents
Current copy of applicable health and safety legislation
Appropriate PPE (for workplace observation)
Clipboard, pens, highlighters, post-it notes, measuring tape, camera, flashlight, carrying bag/knapsack
4. Familiarization tour
Arrange: A tour of the workplace/site(s) accompanied by a knowledgeable organization employee to become familiar with the work processes and workplace/site layout before the actual audit.
5. Pre-audit meeting
Address: Confidentiality and how it will be maintained
Scope of the audit (# of sites, interviewees, etc.)
Verification methods (documentation, observation, interview)
Minimum performance standards
Procedure for handling and communicating auditor concerns e.g. dangerous situations, illegal activities etc.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 8
COR™ 2020 Audi t Handbook
Audit Tool Format
The COR™ 2020 audit tool is divided into 14 elements. Below is a snapshot of a page from the
Audit Tool.
The interview questions are also provided in a separate document if the auditor prefers to use
them in this format. This is available through the e-file submission tool at ihsa.ca/cor-home.
Audit Tool Page Format
Element identification
Maximum item score allowed
To be filled in according to scoring guidelines
Audit Question
Question Auditor’s comments
Verify information using one or more of these methods:
Documentation
Interview
Observation
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 9
COR™ 2020 Audi t Handbook
Verification Techniques
The COR™ 2020 Audit uses three methods to verify implementation of the OHSMS: document
review; interview; and observation.
Verification Technique
The auditor must use one or more of the specified verification techniques, "documentation", "interview'', "observation", to determine the achieved score.
If one technique is listed, only that method is required to determine the achieved score.
A filled background in this category alerts the auditor that an interview may be required to satisfy the question criteria.
Where two verification methods are listed, the auditor may be required to perform both.
If the verification techniques are connected by "and", both methods must be used, and the question criteria satisfied to achieve the maximum score.
If the verification techniques are connected by "or", the auditor selects one method and if the question criteria is satisfied, the maximum score is achieved.
The filled background reminds the auditor that an interview may be required to satisfy the question criteria.
Documentation
Observation
Interview
Documentation and
Observation
Documentation or
Observation
Documentation and
Interview
Documentation or
Interview
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 10
COR™ 2020 Audi t Handbook
Scoring Legislated Requirements
All questions identified as legislated (*) must achieve a full score (100%) to pass the audit.
If you are not fully compliant with all the legislated requirements, you will need to take
action and become 100% compliant before you send in the audit for assessment. Please
acknowledge that this performance gap existed, has been corrected, and documented in
your auditor notes. This should also be documented on your corrective action plan and
submitted to IHSA.
NOTE: If the legislated requirement is not applicable (N/A), enter the full score in the score
achieved column and note the N/A, and reason for applying it, in the auditor’s notes. IHSA
will adjust the audit score to reflect the N/A if it is applicable.
Scoring
Every audit question is verified by appropriate documentation, observation and/or interview.
Every question in the audit must have a score assigned to it and it must be recorded in the
“score achieved” column.
A score of zero (0) is recorded where there is no evidence that a question has been
implemented. Full marks are assigned when there is evidence to show that the question has
been implemented and there are documents, interviews and/or observations to show this.
Partial scores can be applied to specific questions in the audit tool.
Not all audit questions may apply to an organization’s operations. When this occurs, enter
the full score in the score achieved column and note the N/A, and reason for applying it, in
the auditor’s notes. IHSA will adjust the audit score to reflect the N/A if it is applicable.
Legislated items are identified by an asterisk in the legislated column
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 11
COR™ 2020 Audi t Handbook
The following examples provide detail on the “Score Possible” and partial scores:
Score Possible
Score Possible The number value represents the maximum score allowed for this Audit Question.
A clear background signifies the score is either the maximum allowed or zero (0).
A filled background signifies the maximum score, but allows for a partial score if the auditor determines that some, but not all of the item criteria have been satisfied.
A filled background with a split cell signifies that two verification techniques are used to verify the element question and that a partial score may be assigned to each technique.
3
4
3
2
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 12
COR™ 2020 Audi t Handbook
Partial Scores
Partial scores are recorded when there is some evidence that a question has been implemented
but not enough to prove that the question has been fully implemented.
Range Scoring Guide
Maximum Score
Zero
Fully Compliant
Partially Compliant
Not Compliant
Minimum Scores for Passing the COR™ 2020 Audit
The scoring requirements are:
Minimum score of 80% for the overall audit
Minimum score of 65% on each element
Must obtain 100% on all items identified as legislated requirements
If, while completing the internal audit you identify a performance gap in your OHSMS that places
you below the minimum passing score required, you must take action by creating and
implementing a corrective action plan prior to sending the audit to IHSA for review.
Auditor’s Notes
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 13
COR™ 2020 Audi t Handbook
The auditor is required to write comments in the auditor’s notes section. These include:
Reference to where supporting evidence is found (document page number or document title)
Brief explanation of what documents are being provided
Reference to support material (forms, minutes) that are used for verification
Detailed notes about what was observed by the auditor
Detailed descriptions of what the photograph demonstrates if it is used to validate
observations
Reason for assigning a score of zero, partial score or N/A
Any other comments or reminders which may assist the auditor
NOTE: The IHSA Auditor reviewing the audit will be using the information in the Auditor’s
Notes to navigate the audit submission. The IHSA Auditor will only consider evidence
that is referenced in the Auditor’s Notes and is accurately cross referenced to the audit
question it is validating.
Calculations
At the end of each element, there is a space for the score for the element. The Audit Tool will
automatically calculate the score.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 14
COR™ 2020 Audi t Handbook
2. Performing the Audit
Once the preparation has been done, the auditor is ready to proceed with gathering the
information required by the COR™ 2020 Audit. This involves reviewing the documentation for
the organization’s OHSMS, as well as, gathering supporting evidence by obtaining records,
interviewing employees and observing work practices.
Document Review
The documentation review and verification must be done before the interview and observation
portions of the audit.
The document review involves assessing the content and completeness of the organization’s
health and safety manual and any records and/or forms pertaining to health and safety.
The auditor is looking for evidence of organization/work specific practices and procedures.
Records and forms are examined for completeness by for example: checking for dates,
frequency, agenda items, signatures and attendance.
Three consecutive samples of evidence must be made available. See Example 2
Ensure that you have highlighted and cross referenced the specific verifying information in your
health and safety program manual and on the records and forms that are being submitted. Add
in the element and question number reference from the audit tool (Examples 1 and 2)
Example 1
SAMPLE Construct ion Company Inc. Health and Safety Manual
Issue Date: January 2002
Section 9 Page 1
Workplace Inspections Revised: January 2012 Reviewed by: M. Truwe CEO
Purpose
Inspecting the workplace to ensure that the appropriate controls are in agreement of the company health and safety
program. Inspections can help identify problems and assess risks before accidents or injuries occur.
1. Supervisors and health & safety reps will conduct documented workplace inspections.
2. The inspections will cover all company premises and job sites.
3. The INS Form is to be used as a guideline since specific sites may have unique situations and potential hazards that
may not be covered by this list.
4. Planned inspections will occur weekly on project sites and monthly at the company premises.
5. Review previous inspection records and note any commonly reported hazards.
6. Use your eyes, ears and other senses to identify actual or potential problems as you go about your inspection.
7. Record the hazards on the INS Form.
8. When unsafe conditions require immediate action, correct the situation.
9. A copy of the inspection form will be kept on the project.
Item 9.2
Item 9.2 (d)
Item 9.2 (d)
Item 9.2 (h)
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 15
COR™ 2020 Audi t Handbook
Example 2
Site/Contractor Name: SAMPLE Construction Date: 25/05/20
Site/Contractor Name: SAMPLE Construction Date: 27/04/20
Ref. Item 9.3
Site/Contractor Name: SAMPLE Construction Date: 25/05/20
Location: No. of Workers
53 Conducted By:
S – Satisfactory NS - Not Satisfactory NA - Not Applicable
Item Inspected S NS N/A Immediate Action
1. Site Access
Clean, level around
Adequate ramps
Adequate stairs
Adequate ladders
Other
2. Housekeeping
Clear walkways
Documents required for verification may include but are not limited to:
Organizational chart
Health and Safety policy statement
Orientation records and individual training records for all employees [as required]
Hazard assessment
Organization rules, safe work practices and safe job procedures (controls)
Equipment/tool maintenance log and inspection checklists
Incident reports
Health and safety statistical reports
Completed workplace inspection reports (including completed corrective action plans)
Emergency response plans
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 16
COR™ 2020 Audi t Handbook
Interviews
The purpose of the interview is to gauge employee understanding of the OHSMS.
Representatives of both management and workers will be interviewed to verify specific audit
questions. The auditor will determine whether the interviewee provides a positive or negative
response and mark the item accordingly.
Example of an Interview Question
9.4 Are pre-use inspections being performed as per the procedure?
Workers Are you required to do pre-use inspections? Please provide some examples.
# of POSITIVE
(+)
# of NEGATIVE
(-) SUBTOTAL
TOTAL (percentage)
9.10 Are the results of workplace inspections communicated to senior management as per the inspection procedure?
Management How are the results of inspections communicated to senior management?
# of POSITIVE
(+)
# of NEGATIVE
(-) SUBTOTAL
TOTAL (percentage)
Use the organizational chart to select a cross section of employees (management and
workers) to interview.
Senior management should ensure interviewees are available and understand the
purpose of the audit.
Interviews will be conducted one-on-one. Group interviews are not acceptable.
The auditor is required to ask each interviewee all questions that apply to their position
(management or worker) and mark them accordingly.
Interview Questions
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 17
COR™ 2020 Audi t Handbook
Ask the questions as they are written. If it is necessary to paraphrase or probe further,
do not change the intent of the question.
Do not provide the answers or lead the respondents to the answers.
In order to achieve a maximum score for all or nothing interview questions, 51% of all
employees interviewed (combined total of management plus workers) must give a
positive response to the question. A positive response is one in which the interviewee
indicates they know about the requirements and what they and others must do.
For partial score interview questions, a minimum of 51% is required to obtain 1
point and a minimum of 75% is required to obtain the full mark.
Determine the number of interviews required by using the Audit Interview Ratio Table.
The auditor may determine that additional interviews are required based on organization
size and diversity of work e.g. organization is divided by region or type of work.
A separate Interview Questions Document is provided for the auditor’s use, if preferred.
If using this separate document, the auditor must ensure the final results (total of all
interviews) are transferred to the COR™ 2020 Audit tool.
Audit Interview Ratio Table
# of employees
# of managers/supervisors
to interview
# of
workers to interview
Total to be interviewed
1 - 10 2 5 7
11 to 25 2 6 8
26 to 50 3 7 10
51 to 100 4 9 13
101 to 200 5 14 19
Over 200 6 24 30
The organization being audited must provide a professional translator for interviews if
there are any language barriers
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 18
COR™ 2020 Audi t Handbook
Observations
The purpose of conducting observations is to verify the information gathered during the
documentation review and the interviews. Specifically, the auditor is visually confirming whether
the workers are following procedures and/or whether the workplace/site conforms to the legal
and organization OHSMS requirements. For example, a health and safety policy is required to
be posted. This can be verified through observation and full marks can be granted if observed.
Enter your detailed observation notes in the auditor’s notes section of the Audit Tool.
The worksites included in the audit must be representative of the overall organization
operations. To determine the number of worksites to visit refer to the Worksite Observations
Guidelines table. In addition to these active sites the main office/shop visit must be included in
the scope of the audit.
Worksite Observations Guidelines
Active Sites Minimum Number of Sites to be Visited*
1 Site must be visited
2 Both sites must be visited
3 - 4 At least 2 sites must be visited
5 - 8 At least 3 sites must be visited
9 - 30 At least one third (1/3) of the sites must be visited
30+ Employer/auditor must contact IHSA to determine representative
sampling for worksite observation
* The main office/shop must be included in addition to these worksites.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 19
COR™ 2020 Audi t Handbook
3. Summarizing the Audit
Audit Summary Report
The Audit Summary Report must be detailed enough for the organization to address the gaps in
their OHSMS. The report should contain the following content and be presented in the post-
audit meeting:
Acknowledgement to the organization and management for their efforts and assistance
during the audit
A short description of the organization being audited including the scope of work,
number of employees, number of workplaces, interviews conducted and any other
relevant information
High level summary of the significant positive findings
Summary of the audit by element, listing existing strengths and areas for improvement.
Suggestion to management to develop, implement and follow-up on the areas for
improvement with a corrective action plan
Thanks to the organization/management for allowing you to present the audit
Corrective Action Plan
The “Corrective Action Plan” is to be completed by the organization being audited (auditee) after
the auditor has presented the complete audit results.
The Corrective Action Plan describes the steps that will be taken to address the deficiencies
identified in the audit report. It will:
● Prioritize identified deficiencies from the audit
● Identify corrective action(s)/improvements required
● Assign responsibility
● Establish implementation/completion dates
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 20
COR™ 2020 Audi t Handbook
Sample Corrective Action Plan
Health and Safety Action Plan for ___________________________ Organization Inc.
Item Action and Target Date By Whom Date Completed
No H&S policy posted at head office [1.1.9]
Post current copy of H&S policy on head office safety board
Bill Kay – Safety Director
March 24, 20XX
Reviewed by: ___________________________ Signature: ____________________
Name and signature (owner/senior management)
Date: _______________________
4. Submitting the Audit
By this phase of the audit process you have determined whether you have passed the audit or if
you need to make improvements to your OHSMS.
If your total audit score is less than 80%, DO NOT
SUBMIT your audit until you have made suitable
improvements to your OHSMS.
If a total score in an individual Element is less than
65%, DO NOT SUBMIT your audit until you have made
suitable improvements to the Element.
If you have scored zero for any of the items marked as
legislated requirements, DO NOT SUBMIT your audit
until you have achieved a full score for that legislated
requirement
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 21
COR™ 2020 Audi t Handbook
IF YOU SUBMIT A FAILED AUDIT IT WILL BE RETURNED
Please review the following information to ensure that your internal audit is complete before
submitting it to IHSA.
1. An electronic copy of your organization Policy and Program, highlighted and cross-
referenced, must be submitted to IHSA with your internal audit using the e-submission tool.
2. Before submitting the audit, ensure that you have made reference in the Auditor’s
Notes, to the page number in your health and safety program on which the
documentation can be verified. See Example – Auditor’s Notes page XX.
3. Ensure that you have highlighted the verifying information in your Health and Safety
Program manual and cross-referenced it to the element question. See Document
Review Example 1 page XX.
4. When you are required to include copies of supplemental documents, such as
completed inspection forms or incident report forms, ensure that you have provided
the audit question number on the top right-hand corner of the document(s) for
reference. If you are verifying frequency, attach copies with 3 consecutive dates, e.g.
three days, weeks or months in a row. See Document Review Example 2 page XX.
Three consecutive samples of evidence must be made available.
Audit Information Form
The Audit Information Form can be found in the COR 2020 Audit Tool as the first excel file. This
form must be completed in full for the audit submission to be considered for review. Should this
document not be complete, the audit will be returned.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 22
COR™ 2020 Audi t Handbook
Audit Submission Checklist
The Audit Submission Checklist is found at the bottom of the Audit Information Form. All
documents and records stated on the Audit Submission Checklist must be included with the
audit submission. Should there be any items missed from the Audit Submission Checklist, the
audit will be returned.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 23
COR™ 2020 Audi t Handbook
B. COR™ 2020 INTERNAL AUDIT EVIDENCE TIPS
INTRODUCTION
Each element in the COR™ 2020 audit is structured in a similar way with questions for
policy, procedure, implementation and document control as they apply to the specific
element.
Policy
Policy is defined as a general commitment, direction or intention and is formally stated by top
management. An effective policy statement expresses top management's commitment to the
implementation and improvement of its management system.
Each element must have a policy statement that is dated and signed by the owner/CEO.
It demonstrates management’s commitment to providing the time, budget and resources
needed to effectively implement the element.
The policy statement may be a few sentences or longer depending on the element.
Procedure
Procedure is defined as a documented, specified method to carry out an activity.
The second question in each element is about the procedure. It specifies all of the requirements
that must be included in your written procedure. Make sure you cover all of these points and can
show the auditor how you did this. A copy of the written procedure must be provided to the
auditor for review.
Implementation
Implementation questions seek to identify evidence that the element is in place and actually
working as per your written procedure. Evidence may be verified through review of
documentation, interviews of managers and workers or observations of the workplace and/or
work in progress. This evidence must demonstrate that you are carrying out the element
activities as specified in your procedure for that element.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 24
COR™ 2020 Audi t Handbook
Document Control
The last question for each element is about maintenance of documents and records related to
the procedure.
Document is defined as medium containing information related to the Occupational Health and
Safety Management System (OHSMS).
Record is defined as a document stating results achieved or providing evidence of activities
performed.
As part of the OHSMS, the organization shall establish, implement, monitor and maintain
procedures to specify which documents and records will be used and maintained.
Documentation
Documentation includes documents and records required by the COR™ 2020 Program and
determined by your organization to be necessary for the effectiveness of your OHSMS.
The creation, collection, retention and distribution of documents and records shall comply with
all applicable legal requirements, collective agreements and organizational policies, as
appropriate.
Control of Documents
At the end of each element, with the exception of Element 1, there is a question that asks if
documents and records maintained as per the procedures relevant to the element. During the
audit you will be asked to show the auditor documents and records that demonstrate that the
specific procedure has been implemented. Element 1.2 Document and Record Control includes
the requirements you will need to meet to receive a full score for this question.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 25
COR™ 2020 Audi t Handbook
AUDIT TIPS
Note: Definitions for bolded terms are included in the Definitions section.
Element 1: Health & Safety Policy and Document and Record Control Evidence Tips
1.1 Health and Safety Policy
The health and safety policy sets the direction for your OHSMS. It confirms senior management’s commitment to providing a healthy and safe work environment.
Does the organization have an OHS policy statement that:
1.1.1 Includes a commitment for senior management to set and review OHS objectives and continual improvement of the OHSMS and OHS performance?
1.1.2 Includes senior management and management’s commitment to provide a healthy and safe work environment for the prevention of injuries and illnesses?
1.1.3 Expresses a commitment to be in compliance with applicable OHS legal and other requirements?
1.1.4 Expresses a commitment to work in a spirit of consultation and co-operation with workers?
1.1.5 Refers to a program that addresses health and safety responsibilities for workplace parties?
1.1.6 Recognizes the right of workers to work in a safe, healthy work environment?
1.1.7 Is signed by the president, CEO or local senior management?
1.1.8 Is current?
1.1.9 Is visibly posted in the workplace? Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
1.1.10 Is reviewed at least annually?
1.1.11 Is communicated and understood by employees?
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 26
COR™ 2020 Audi t Handbook
1.2 Document and Record Control Evidence Tips
A document/record control procedure provides direction to track, manage, and store documents and records and assists with accuracy and due diligence.
1.2.1 Does your organization have a written procedure for documentation, document control and record control that includes:
a) Roles and responsibilities
b) Documents and records determined by your organization to be necessary for the effectiveness of the OHSMS
c) Requirement to ensure documents are approved prior to issue
d) Requirement to review, update, re-approve or withdraw documents as necessary
e) Requirement to ensure changes to, and current revision status of, documents are identified and tracked
f) Requirement to ensure relevant versions of applicable documents are readily available at the point of use
g) Requirement to identify documents of external origin that may be necessary for the planning and operation of the OHSMS
h) Requirement to prevent the unintended use of obsolete documents and identify such documents if they are retained for any purpose
i) Requirement for the identification and retention of records as necessary to demonstrate conformity to the requirements of your OHSMS
j) Requirement for protection of privacy and confidentiality, as appropriate
k) Requirement to ensure documents and records remain legible and readily identifiable
Your procedure should include all items referenced in clauses a through k. Each clause is assigned one point. Only clauses that have been highlighted and properly identified will be considered.
Cross reference your procedure to the procedure requirements a through k. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 1.2.1a.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 27
COR™ 2020 Audi t Handbook
Element 2: Hazard Assessment, Analysis and Control Evidence Tips
Hazard assessment is fundamental to your OHSMS. It is a formalized way to identify your hazards and systematically analyze the risks to determine the necessary controls.
2.1 Does your organization have a documented policy statement for hazard assessment, analysis and control that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 2.1.
2.2 Does your organization have a written procedure for hazard assessment, analysis and control that includes:
a) Roles and responsibilities b) Required competencies for conducting hazard
assessment, analysis and control c) Requirement for involvement of appropriate competent
workplace parties such as workers, supervisors, maintenance, engineering and suppliers in the hazard assessment process
d) Requirement to conduct hazard assessments for all operations, including routine and non-routine, and human factors where work is performed
e) Requirement for reporting actual and potential hazards f) Requirement to conduct risk assessments for identified
hazards:
● Proactively prior to commencement of tasks ● When equipment, material, substance or process is
introduced or changed ● When a change to the OHSMS may impact
workplace operations or activities g) Identification of when to review, and update hazard
assessments such as after investigations, when the phase of project changes; and must be completed at least annually
h) Requirement to identify hazards originating outside of the workplace that may impact OHS within the workplace for which the organization has control
i) Consideration of legal requirements and associated standards and guidelines
j) Consideration of design and layout of the work area, ergonomics, machinery and processes
k) Requirement to utilize a standardized risk rating system to prioritize risks before and after identifying controls
l) Requirement to develop a list of identified critical tasks and/or activities based on the risk rating system
m) Specific forms for recording hazard assessments, analysis and control?
Your procedure should include all items referenced in clauses 2.2a through m. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements a through m. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 2.2a.
Only clauses that have been highlighted and properly identified will be considered.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 28
COR™ 2020 Audi t Handbook
2.3 Are hazard assessments conducted, documented and approved for all operations including routine and non-routine operations and human factors?
2.4 Have hazard assessments been updated as per the procedure?
2.5 Are appropriate workplace parties involved in the hazard assessment process as per the procedure?
2.6 Are workplace and job specific hazards clearly identified in the hazard assessment documents?
2.7 Are risks prioritized before identifying adequate controls?
2.8 Are risks prioritized after identifying adequate controls?
2.9 Is there a list of critical tasks and/or activities that was identified using a company specific risk rating assessment?
2.10 Are documented controls referenced in the hazard assessments?
2.11 Are control measures made available and appropriate employees informed of the control strategies?’
2.12 Are documented controls implemented for identified hazards?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
2.13 Are documents and records maintained as per the procedures in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 2.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 29
COR™ 2020 Audi t Handbook
Element 3: Controls Evidence Tips
Once hazards are identified and assessed, it is necessary to develop formal controls for workplace parties to follow to ensure their safety. Following the hierarchy of controls ensures the most effective controls are in place.
3.1 Does your organization have a documented policy statement for controls that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 3.1.
3.2 Does your organization have a written procedure for controls that includes:
a) Roles and responsibilities
b) Requirement for senior management to approve all controls
c) Requirement to include management and workers in the development and review of controls
d) Taking into account the hierarchy of controls
i. Elimination
ii. Substitution
iii. Engineering controls
iv. Administrative controls
v. Personal protective equipment
e) Taking into account applicable legal and other requirements such as standards, guidelines or manufacturer’s instructions
f) Specific forms for documenting controls
g) Requirement to communicate control measures to affected workplace parties
h) Requirement to make control measures readily available at the point of use as required?
Your procedure should include all items referenced in clauses 3.2a through h. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 3.2a through h. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 3.2a.
Only clauses that have been highlighted and properly identified will be considered.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 30
COR™ 2020 Audi t Handbook
3.3 Have appropriate controls been documented and approved as per the procedure?
3.4 Do the documented controls accurately reflect the organization’s activities?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
3.5 Have controls been developed following the hierarchy of controls?
3.6 Have the documented controls been communicated to affected workplace parties?
3.7 Are the controls understood by workers? Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
3.8 Are controls made readily available at the point of use?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
3.9 Are the requirements for controls followed by all workplace parties?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
3.10 Do both management and workers participate in the development and review of controls?
3.11 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 3.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 31
COR™ 2020 Audi t Handbook
Element 4: Procurement and Contractor Management Evidence Tips
When hiring service providers they may be exposed to, or create new hazards, in your workplace. It is important to make sure these hazards are assessed and controlled.
4.1 Does your organization have a documented policy statement for procurement and contractor management that is signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 4.1.
4.2 Does your organization have a written procedure for procurement and contractor management that includes:
a) Roles and responsibilities
b) Requirement for the contractor/service provider to complete a hazard assessment as per Element 2 Hazard Assessment, Analysis and Control; and Element 3 Controls
c) OHS criteria for selecting, monitoring and evaluating contractor/service providers that includes:
i. The ability and competency of the contractor to be able to assess/analyze and control hazards arising from their own work that may impact the organization’s workers
ii. The ability and competency of the contractor to be able to assess/analyze and control hazards arising from the organizations work that may impact the contractor’s workers
d) Communication with workplace parties when there are changes affecting the health and safety of the work
e) Requirement for the organization to lead the coordination of their site specific OHS requirements on multi-employer workplaces
f) Specific forms for evaluating contractors and service providers?
Your procedure should include all items referenced in clauses 4.2a through f. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 4.2a through f. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 4.2a.
Only clauses that have been highlighted and properly identified will be considered.
4.3 Has your organization followed its OHS criteria for selecting contractors and service providers?
4.4 Has your organization monitored your contractors and service providers as per the procedure?
4.5 Has your organization evaluated the contractors and service providers as per the procedure?
4.6 Has your organization communicated with relevant workplace parties when changes have occurred?
4.7 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 4.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 32
COR™ 2020 Audi t Handbook
Element 5: Company Rules Evidence Tips
Company rules establish the OHS norms within the workplace. They may have many titles such as code of conduct or golden rules.
5.1 Does your organization have a documented policy statement for company rules that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 5.1.
5.2 Does your organization have a written procedure for company rules that includes:
a) Roles and responsibilities for setting, implementing and complying with company rules
b) Ensuring both standard and work location specific rules are available
c) Requirement for company rules to be written and either visibly posted or provided to each employee
d) Ensuring company and workplace specific rules are clearly explained to workers in a way that they understand them
e) Ensuring company rules are applied and enforced consistently throughout the organization
f) A progressive disciplinary procedure
Your procedure should include all items referenced in clauses 5.2a through f. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 5.2a through f. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 5.2a.
Only clauses that have been highlighted and properly identified will be considered.
5.3 Are company rules clearly stated in writing?
5.4 Are the rules visibly posted or provided to each employee?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
5.5 Do workers understand the company’s rules?
5.6 Are the company rules applied and enforced consistently throughout the company?
5.7 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 5.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 33
COR™ 2020 Audi t Handbook
Element 6: Personal Protective Equipment Evidence Tips
Personal protective equipment (PPE) is a common control method for many hazards. PPE is the last resort in the hierarchy of controls. When used it is important to ensure all other possibilities for controls have been considered. PPE always requires training on fit, care and use to be effective.
6.1 Does your organization have a documented policy statement for personal protective equipment that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 6.1.
6.2 Does your organization have a written procedure for personal protective equipment that includes:
a) Roles and responsibilities
b) Ensuring activities requiring PPE are documented
c) Ensuring specific criteria is used to select appropriate PPE for all activities
d) Written rules and/or guidelines for the proper fitting, care and use of PPE and ensure workers are made aware of them
e) Ensuring that appropriate PPE is provided and/or made available to workers for specific activities
f) Requirement for inspection and maintenance of PPE as per manufacturer’s and legislative requirements
g) Ensuring management, supervisors, workers, sub-contractors and suppliers of service use required PPE
h) Specific forms for inspecting personal protective equipment?
Your procedure should include all items referenced in clauses 6.2a through h. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 6.2a through h. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 6.2a.
Only clauses that have been highlighted and properly identified will be considered.
6.3 Has the organization documented the required PPE
for all activities?
6.4 Is PPE selected as per the procedure?
6.5 Are there written rules and/or guidelines for the proper fitting, care and use of PPE?
6.6 Are workers made aware of the requirements for the proper fitting, care and use of PPE?
6.7 Is adequate PPE provided and made available to workers for specific activities?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
6.8 Are personnel inspecting PPE as per manufacturer’s and legislative requirements?
6.9 Do management, supervisors, workers and sub-contractors/suppliers of services use required PPE?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
6.10 Are documents and records maintained as per the procedure 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 6.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 34
COR™ 2020 Audi t Handbook
Element 7: Preventative Maintenance Evidence Tips
Preventative maintenance is a formalized system to ensure that equipment, tools, vehicles and facilities are kept in safe working order.
7.1 Does your organization have a documented policy statement for preventative maintenance that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 7.1.
7.2 Does your organization have a written procedure for preventative maintenance that includes:
a) Roles and responsibilities
b) An inventory of items to be maintained (whether owned, leased or rented)
c) Requirement for use of preventative maintenance schedules
d) Requirement to meet manufacturers’ preventative maintenance guidelines and legislated requirements
e) Requirement to keep records including corrective actions taken
f) Qualifications for worker(s) performing the inspection and maintenance
g) Requirement to remove overdue and/or defective tools, equipment, facilities and vehicles from service
h) Specified forms and/or software for scheduling and tracking preventative maintenance?
Your procedure should include all items referenced in clauses 7.2a through h. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 7.2a through h. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 7.2a.
Only clauses that have been highlighted and properly identified will be considered.
7.3 Is there an inventory of items to be maintained?
7.4 Are there schedules that meet manufacturer’s preventative maintenance guidelines and legislated requirements?
7.5 Is preventative maintenance being performed as planned based on schedules and preventative maintenance requirements?
7.6 Do the records include corrective action taken?
7.7 Does a competent/qualified worker perform the inspection and maintenance as per the procedure?
7.8 Have defective vehicles, tools and equipment been removed from service as per the procedure?
7.9 Have vehicles, tools and equipment that are overdue for preventive maintenance been removed from service as per the procedure?
7.10 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 7.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 35
COR™ 2020 Audi t Handbook
Element 8: Training and Communication Evidence Tips
Training and communication are fundamental to ensure that workplace parties understand their roles and responsibilities to implement the OHSMS. Training aids in the development and maintenance of job specific knowledge and skills needed to work safely and efficiently. Good communication allows all workplace parties to stay current with the OHSMS and deal with any issues quickly and effectively.
8.1 Training
8.1.1 Does your organization have a documented policy statement for training that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 8.1.1
8.1.2 Does your organization have a written procedure for training that includes:
a) Setting roles and responsibilities for those administering and managing the training procedure
b) Identifying competencies for each task/role
c) Ensuring in-house trainers are competent
d) Determining OHS training needs by:
i. Conducting training needs analysis
ii. Reviewing legislated and other training requirements
iii. Taking into consideration different levels of responsibilities, abilities, language skills and literacy
iv. Including information on the organization’s OHSMS including purpose, roles, responsibilities and rights, importance of conformity, potential consequences for deviations or noncompliance and importance of workers’ participation within the OHSMS
e) Requirement to provide training prior to the worker performing the relevant task
f) An orientation program that:
i. Is completed prior to starting work
ii. Is provided for new and young workers, returning workers, change of role
iii. Is mandatory for all workers
g) How the training will be administered and managed
h) Evaluation of learning
i) Method for maintaining training and orientation records?
Your procedure should include all items referenced in clauses 8.1.2a through i. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 8.1. a through i. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 8.1.2a.
Only clauses that have been highlighted and properly identified will be considered.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 36
COR™ 2020 Audi t Handbook
8.1.3 Does the training accommodate differing levels of responsibilities?
8.1.4 Have competencies been identified for each task/role?
8.1.5 Has the organization conducted a training needs analysis as per the procedure?
8.1.6 Have employees received training that is required by legislation?
8.1.7 Have employees received training as per the procedure?
8.1.8 Is the training provided prior to the worker performing the relevant task?
8.1.9 Is orientation mandatory for all workers?
8.1.10 Has orientation training been provided as per the procedure?
8.1.11 Is in-house training delivered by a qualified competent person as per the procedure?
8.1.12 Does the organization evaluate learning as per the procedure?
8.1.13 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 8.1.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 37
COR™ 2020 Audi t Handbook
8.2 Communication Evidence Tips
8.2.1 Does your organization have a documented policy statement for communication that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 8.2.1.
8.2.2 Does your organization have a written procedure for communication that includes:
a) Roles and responsibilities
b) Senior management holding regularly scheduled organization-wide OHS meetings with all employees that include the OHSMS and its implementation at least annually
c) Communication delivered in a manner that is understood by the receiver of the message and considers ability, language skills and literacy
d) Opportunity for input from workers
e) Receiving, documenting and responding to internal and external OHS communications
f) Tailgate or tool box talks or their equivalent
g) Specific forms for recording attendance, agendas, meeting minutes and tool box talks
h) Requirement to maintain records?
Your procedure should include all items referenced in clauses 8.2.2a through h. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 8.2.2a through h. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 8.2.2a.
Only clauses that have been highlighted and properly identified will be considered.
8.2.3 Does senior management of the organization hold scheduled company-wide OHS meetings with all employees?
8.2.4 Does senior management attend/participate in organization-wide OHS meetings with all employees?
8.2.5 Does two-way communication exist during these meetings?
8.2.6 Are tailgate or tool box talks or their equivalent held as scheduled?
8.2.7 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 8.2.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 38
COR™ 2020 Audi t Handbook
Element 9: Workplace Inspections Evidence Tips
Workplace and pre-use inspections are a proactive method to check if controls are working, identify hazards and ensure that corrective actions are taken. There are legislated requirements for workplace and pre-use inspections. It is a good practice to involve as many workers and managers as possible in the inspection process.
9.1 Does your organization have a documented policy statement for workplace inspections that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 9.1.
9.2 Does your organization have a written procedure for workplace inspections that includes:
a) Roles and responsibilities
b) Requirement to conduct and keep records for workplace inspections including identifying and preventing potential non-conformities and corrective actions
c) Requirement to conduct and keep records for pre-use inspections of vehicles, machines, tools and equipment including corrective actions
d) Inspection frequencies and who is responsible to conduct them
e) Worker participation in the inspection process
f) Requirement to meet all legislation (e.g. Regulation 1101 First Aid Requirements) and manufacturer’s requirements
g) What must be inspected
h) Specific forms for recording workplace and pre-use inspections
i) Requirement to communicate inspection results to Senior Management and other relevant workplace parties?
Your procedure should include all items referenced in clauses 9.2 a through i. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 9.2a through i. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 9.2a.
Only clauses that have been highlighted and properly identified will be considered.
9.3 Are workplace inspections being conducted using the specific forms and checklists as per the procedure?
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 39
COR™ 2020 Audi t Handbook
9.4 Are inspection frequencies being adhered to?
9.5 Are assigned personnel performing inspections as required?
9.6 Are pre-use inspections being performed as per the procedure?
9.7 Are workplace and pre-use inspections meeting all legislative and manufacturer’s requirements?
9.8 Are workers involved in the general workplace inspection process?
9.9 Are identified deficiencies corrected in a timely manner as per the procedure?
9.10 Are the results of workplace inspections communicated to senior management as per the procedure?
9.11 Are inspection reports communicated to all relevant workplace parties?
9.12 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 9.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 40
COR™ 2020 Audi t Handbook
Element 10: Investigations and Reporting Evidence Tips
Investigations are a method to gather information to determine the cause(s) of an incident. Corrective and preventative actions are identified and recommendations made to prevent similar incidents. There are both internal and legal reporting requirements.
10.1 Does your organization have a documented policy statement for investigations and reporting that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 10.1.
10.2 Does your organization have a written procedure for
investigations and reporting that, at minimum, meets legislated requirements and includes:
a) Roles and responsibilities for workplace parties to report incidents, including near misses, conducting investigations in a timely manner and for implementing corrective and preventive actions identified as a result of investigations
b) Requirement that training is provided in legislative and organization specific reporting requirements and investigations procedures
c) Requirement to take action to mitigate any additional consequences of the incident
d) Determination of OHS deficiencies including root causes of the incident
e) Determination and implementation of corrective and preventative actions
f) Communication of investigation results and corrective and preventative actions to interested parties
g) A process measuring the effectiveness of corrective and preventative actions
h) Specific forms for investigations
i) Methods for maintaining records of incident reporting and investigation results?
Your procedure should include all items referenced in clauses 10.2 a through i. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 10.2a through i. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 10.2a.
Only clauses that have been highlighted and properly identified will be considered.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 41
COR™ 2020 Audi t Handbook
10.3 Do records show that the incident investigation and reporting procedure is being followed?
10.4 Are all workplace parties aware of reporting procedures?
10.5 Have required personnel been trained in legislative and organization specific reporting requirements and investigation procedures?
10.6 Are appropriate personnel involved in investigations as per the incident investigation and reporting procedures?
10.7 Are opportunities for corrective and preventative actions being identified and addressed?
10.8 Are corrective and preventative actions being implemented as per the procedure?
10.9 Are corrective and preventative actions communicated to workers?
10.10 Is the organization measuring the effectiveness of the corrective and preventative actions?
10.11 Are documents and records maintained as per the procedure in 1.2 Documents and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 10.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 42
COR™ 2020 Audi t Handbook
Element 11: Emergency Preparedness Evidence Tips
Emergency response plans must be developed for potential emergency situations that are identified through the hazard assessment process. There are legislated requirements for emergency response.
11.1 Does your organization have a documented policy statement for emergency preparedness that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 11.1.
11.2 Does your organization have a written procedure for emergency preparedness that includes:
a) Roles and responsibilities
b) Identification of potential emergency situations that are linked to completed hazard assessments
c) Documented response plans including roles and responsibilities of relevant employees during emergencies
d) Input to the response plan from relevant interested parties
e) Identification of resources needed to implement the emergency response plans
f) Requirement for emergency equipment to be in place, well-marked and regularly inspected and maintained
g) Prevention or minimization of injury or occupational illness for the identified emergency situations
h) First aid requirements that includes:
i. First aid station, facilities and supplies
ii. Qualified first aiders
iii. Provision to transport injured workers to medical facility
i) An appropriate emergency communication system
j) Requirement for emergency response training appropriate for employees’ role
k) Periodic testing of the emergency response plans (e.g. drills) and the maintenance of records of testing and corrective actions
l) Periodic review of emergency procedures and response plans at least annually and revision as appropriate
m) Communication of relevant information to all involved including workers, visitors, contractors, emergency response services, government authorities and the community regarding emergency response
n) Specific forms for documenting the implementation of emergency response plans e.g. inspection of equipment and testing emergency response?
Your procedure should include all items referenced in clauses 11.2a through n. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 11.2a through n. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 11.2a.
Only clauses that have been highlighted and properly identified will be considered.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 43
COR™ 2020 Audi t Handbook
11.3 Do documented Emergency Preparedness and Emergency Response Plans include the most appropriate responses to identified hazards and address the potential for emergency situations?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
11.4 Are the emergency response plans reviewed as per the procedure?
11.5 Have emergency response resources been identified and are they available?
11.6 Do the plans include input from relevant interested parties?
11.7 Do the plans define the roles and responsibilities of relevant employees and include training in emergency procedures that is appropriate to the roles and responsibilities?
11.8 Is relevant information communicated to relevant workplace parties regarding emergency response, as per the procedure?
11.9 Is an appropriate emergency communication system in place to alert workplace parties to the emergency?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
11.10 Has the plan been tested for deficiencies and corrective action taken (if necessary)?
11.11 Are the appropriate number and type of fire extinguishers at marked locations?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 44
COR™ 2020 Audi t Handbook
11.12 Are workers who are required to use fire extinguishers trained how to use them?
11.13 Are fire extinguishers regularly inspected and maintained as per manufacturer and legislative requirements?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
11.14 Are required first aid stations, facilities and supplies available?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
11.15 Are qualified first aiders available on every shift?
11.16 Periodic inspection of first aid facilities and equipment?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
11.17 Is all other emergency response equipment regularly inspected and maintained?
11.18 Is there provision for transporting an injured worker to a hospital or medical facility?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
11.19 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 11.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 45
COR™ 2020 Audi t Handbook
Element 12: Statistics & Records Evidence Tips
Statistics and records must be collected and reviewed to get a clear picture of your organization’s OHS performance. This information helps identify gaps and trends in your OHSMS. This can be done weekly, monthly, quarterly or annually.
12.1 Does your organization have a documented policy statement for statistics and records that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 12.1.
12.2 Does your organization have a written procedure for statistics and records that includes:
a) Roles and responsibilities
b) Requirement to measure OHS performance at a specified frequency, at minimum annually
c) Qualitative and quantitative measurements appropriate to the organization
d) Leading and lagging performance indicators
e) Comparison of current health and safety performance with past performance
f) Analysis of statistics and identification of trends
g) Analysis of first aid treatment records
h) Results recorded and communicated to relevant workplace parties
i) Specified forms and/or software as needed?
Your procedure should include all items referenced in clauses 12.2a through i. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 12.2a through i. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 12.2a.
Only clauses that have been highlighted and properly identified will be considered.
12.3 Are health and safety summaries developed and maintained?
12.4 Is OHS performance being measured at a specified frequency as per the procedure?
12.5 Does the organization compare their health and safety performance with past performance?
12.6 Are the statistics analyzed and needs or trends identified?
12.7 Are first aid treatment records analyzed?
12.8 Have results been communicated to relevant workplace parties as per the procedure?
12.9 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 12.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 46
COR™ 2020 Audi t Handbook
Element 13 Legislation and Other Requirements Evidence Tips
Your organization must identify all applicable OHS legislation and ensure compliance in the workplace. There are other requirements such as standards, codes, guidelines and manufacturer’s specifications that must be considered.
13.1 Does your organization have a documented policy statement for legislation and other requirements that is current, signed and dated by senior management?
Only element specific policy statements will be considered. It should be a distinct statement focusing on senior management commitment for this element.
Cross reference the date and signature and number it 13.1.
13.2 Does your organization have a written procedure for legislation and other requirements that includes:
a) Roles and responsibilities
b) Identification of applicable legislation, regulations, standards and any other requirements
c) Methods to ensure compliance with applicable legislation
d) All documentation related to legislation, regulations, standards and any other requirements are up to date
e) Visible posting or availability of relevant legislation at each workplace as required
f) Evaluation of compliance to legislation at regularly planned intervals and retention of records of evaluations
g) Specific forms as required?
Your procedure should include all items referenced in clauses 13.2a through g. Each clause is assigned one point.
Cross reference your procedure to the procedure requirements 13.2a through g. To show where each item is found, highlight and number your procedure.
For example, the section of your procedure that has roles and responsibilities would be highlighted and numbered 13.2a.
Only clauses that have been highlighted and properly identified will be considered.
13.3 Has the organization identified legislation, regulations, standards and any other requirements that apply to them?
13.4 Is all required documentation current?
13.5 Has the organization evaluated their compliance to current applicable legislation as per the procedure?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
13.6 Are copies of relevant legislation readily available and/or posted when required at each workplace?
Observation: Include in auditor/observation notes details regarding the observations and cross reference location of any pictures in your internal audit submission.
13.7 Are legislated posting requirements being met?
13.8 Are documents and records maintained as per the procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per the forms required in your procedures. See 1.2 and 13.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 47
COR™ 2020 Audi t Handbook
Element 14: Management Review and Management of Change Evidence Tips
14.1 Management Review
Senior management must review the effectiveness of the OHSMS at regularly planned intervals, and at
least annually. The review will help senior management identify OHS objectives and aid in the
development of action plans for continual improvement of the OHSMS.
14.1.1 Does your organization have a documented policy
statement for senior management review that is current,
signed and dated by senior management?
Only element specific policy
statements will be considered.
It should be a distinct statement
focusing on senior management
commitment for this element.
Cross reference the date and
signature and number it 14.1.1.
14.1.2 Does your organization have a written procedure for
management review that includes:
a) Roles and responsibilities
b) The following inputs to the senior management
review:
i. Evaluation of the effectiveness of all elements
of the OHSMS
ii. Status of actions from previous management
reviews
iii. Results of internal audits, including COR™
audits
iv. Evaluations of compliance with legal
requirements
v. Results of participation and consultation with
employees/Health and Safety Representative
/Joint Health and Safety Committee
vi. Communication from external parties
vii. OHS performance of the organization
viii. Evaluation of the extent to which OHS
objectives have been met
ix. Status of incident investigations, trends
identified, implementation of corrective
actions, implementation of preventative
actions and status of actions taken
x. Changing circumstances related to OHS such
as developments in legal requirements or
technology
xi. Identified barriers to worker participation in the
OHSMS\
xii. Recommendations for improvement
Your procedure should include all
items referenced in clauses 14.1.2
a through e. Each clause is
assigned one point.
Cross reference your procedure to
the procedure requirements
14.1.2a through e. To show where
each item is found, highlight and
number your procedure.
For example, the section of your
procedure that has roles and
responsibilities would be
highlighted and numbered 14.1.2a.
Only clauses that have been
highlighted and properly identified
will be considered.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 48
COR™ 2020 Audi t Handbook
c) The following outputs to the management review:
i. OHS policy updates
ii. Measurable OHS objectives
iii. Action plan to achieve objectives
iv. Required resources
v. Revisions to any other elements of the
OHSMS as appropriate
vi. Removed barriers to worker participation in the
OHSMS
vii. Communication of the objectives and action
plan(s) to all employees
d) Specified forms for recording Management
Review
e) Method for maintaining records?
14.1.3 Does the review include all inputs as per the procedure?
14.1.4 Have measurable OHS objectives been identified as a
result of the review as per the procedure?
14.1.5 Have OHS policies been reviewed and updated?
14.1.6 Has an action plan been developed and resources
identified to meet the objectives as per the procedure?
14.1.7 Have the OHS objectives and action plan(s) been
communicated to all employees as per the procedure?
14.1.8 Are documents and records maintained as per the
procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as
per the forms required in your
procedures. See 1.2 and 14.1.2.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 49
COR™ 2020 Audi t Handbook
14.2 Management of Change Evidence Tips
Management of change is a process to ensure that when changes occur hazards are assessed and
addressed. Some examples of changes are new legislation, new products, and different work processes.
14.2.1 Does your organization have a documented policy
statement for management of change that is current,
signed and dated by senior management?
Only element specific policy
statements will be considered.
It should be a distinct statement
focusing on senior management
commitment for this element.
Cross reference the date and
signature and number it 14.2.1.
14.2.2 Does your organization have a written procedure for
management of change that includes:
a) Roles and responsibilities
b) Identification of when the management of
change procedure will be implemented which
includes at a minimum:
i. Changes in legal requirements
ii. Significant changes in work processes,
control measures, equipment, organization,
work location
iii. Introduction of new products, processes or
services
iv. Introduction of new developments in OHS
knowledge or technology
c) Requirement to apply Element 2 Hazard
Assessment, Analysis and Control and Element
3 Controls to any identified changes
d) Provision of information and training for relevant
workplace parties where appropriate?
Your procedure should include all
items referenced in clauses 14.2.2a
through d. Each clause is assigned
one point.
Cross reference your procedure to the
procedure requirements 14.2.2a
through d. To show where each item is
found, highlight and number your
procedure.
For example, the section of your
procedure that has roles and
responsibilities would be highlighted
and numbered 14.2.2a.
Only clauses that have been
highlighted and properly identified will
be considered.
14.2.3 Has a hazard assessment been done as a result of
changes identified as per the procedure?
See 2.3
14.2.4 Has the organization developed relevant controls as a
result of the hazard assessment?
See 2.10. 2.11
14.2.5 Have the controls been communicated and training
provided to relevant workplace parties?
See 2.12
14.2.6 Are documents and records maintained as per the
procedure in 1.2 Document and Record Control?
Provide 3 samples of evidence as per
the forms required in your procedures.
See 1.2 and 14.2.2.
If you have any questions or concerns when completing the audit, contact IHSA.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 50
COR™ 2020 Audi t Handbook
DEFINITIONS
Action Plan: A plan that identifies the tasks to be accomplished, assigns responsibilities for
completing each task, identifies the timeline in which it is to be completed, and records the
actual action taken and completion dates.
Audit: Systematic, independent and documented process for obtaining evidence and evaluating
it objectively to determine the extent to which pre-determined criteria are fulfilled.
Audit Program: A set of one or more audits planned for a specific time frame and directed
towards a specific purpose.
Competency: A person performing a task for, or on behalf of, the organization is competent to
do so by means of appropriate:
a) Knowledge of the hazards and risks associated with the tasks for the operations and
activities
b) Demonstrated understanding and working knowledge of the control measures
associated with the hazards and risks
c) Training with regard to the hazards, risks and associated control measures
d) Aptitudes, such as skillset, ability and willingness to deal with the hazards, risks and
control measures
Compliance: Meeting all requirements outlined within applicable legislation and regulations.
Conformity: Fulfillment of a requirement.
Consultation: Process by which the organization seeks the views of the workers, worker
representatives, and workplace parties before it makes a decision.
Continual Improvement: Recurring activity to enhance performance and achieve a
measurable result.
Contractor: Person or organization providing services to another organization in accordance
with agreed upon specification, terms and conditions.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 51
COR™ 2020 Audi t Handbook
Corrective Action: Action to eliminate the cause of a non-conformity and to prevent
recurrence. There can be more than one cause for a non-conformity.
Document: Medium containing information related to the OHSMS.
Hazard: Source, situation or act with a potential for harm in terms of human injury.
Hazard Assessment: The process of conducting a systematic review to:
Identify hazards associated with work activities
Analyze or evaluate the risks(s) associated with the hazards
Determine appropriate ways to eliminate or control the hazards
This can be broken down into 3 levels:
1. Formal Hazard Assessment: A documented overall hazard assessment encompassing
all of the organizations potential hazards/ risks.
2. Site Specific Hazard Assessments: A documented hazard assessment identifying any
hazards specific to the work sites.
3. Field Level Hazard Assessment: a documented hazard assessment, which can identify
the specific conditions present where the work is being performed.
Human Factors: Is concerned with fitting the job or task to the physical and mental capabilities
of the worker. Also commonly called ergonomics.
Incident: Work related event(s) in which an injury, fatality or occupational illness occurred; and
includes event(s) where no injury or illness occurred, such as a near hit or property damage.
Interested Parties: Persons or groups, inside or outside the workplace, concerned with or
affected by OHS performance of an organization.
Legal Requirements: All applicable legislation, including but not limited to the Occupational
Health and Safety Act and its regulations.
Management: People who have care and control over people and/or processes.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 52
COR™ 2020 Audi t Handbook
Non-conformity: Non-fulfillment of a requirement.
Objective: Result to be achieved. An objective can be expressed in many ways, e.g. as an
intended outcome, a purpose, an operational criterion, as an OHS objective or by the use of
other words with similar meaning (e.g. aim, goal, or target).
Occupational Health and Safety (OHS): Conditions and factors that affect, or could affect the
health and safety of employees or other workers, inclusive of temporary workers and contractor
personnel, visitors, suppliers, vendors, or any other person in the workplace.
Occupational Health and Safety Management System (OHSMS): As defined in the OHSA
“means a coordinated system of procedures, processes and other measures that is designed to
be implemented by employers in order to promote continuous improvement in occupational
health and safety.
OHS Objective: OHS goal, in terms of OHS performance, that an organization sets itself to
achieve.
OHS Performance: Measureable results of an organization’s management of its OHS risks.
OHS Policy: Overall intentions and direction of an organization related to its OHS performance
as formally expressed by senior management in relation to the implementation of the OHSMS.
Organization: Company, corporation, firm, enterprise, authority or institution, or part or
combination thereof, whether incorporated or not, public or private, that has its own functions,
management and administration.
Other Requirements: Requirements or provisions the organization subscribes, however are
not legally binding, such as industry standards.
Participation: Involvement of workers, or worker representatives, in decision-making
process(es) regarding the OHSMS.
Plan: Detailed method for doing or achieving something.
I n f rast ructure Hea l t h & Saf e ty Associa t ion ( IHS A) © 0 7 /20 53
COR™ 2020 Audi t Handbook
Policy: A policy is a general commitment, direction or intention and is formally stated by top
management. A quality policy statement should express top management's commitment to the
implementation and improvement of its management system.
Preventative Action: Action to eliminate the cause of potential non-conformity or other
potential undesirable potential situation. There can be more than one cause for a potential
nonconformity. (For the purposes of this Standard, this refers to any action taken to fix a
potential OHS problem.)
Procedure: A documented, specified method to carry out an activity.
Process: A set of interrelated or interacting activities that transforms inputs into outputs.
Qualitative: Relating to the nature or description of something, rather than to its quantity.
Quantitative: The measurement or number of something rather than its quality.
Record: Document stating results achieved or providing evidence of activities performed.
Residual Risk: Combination of the likelihood of the occurrence after the hierarchy of controls
has been implemented for an identified hazard.
Risk: Combination of the likelihood of an occurrence of a hazardous event or exposure(s) and
the severity of injury or occupation illness that can be caused by the event or exposure(s).
Risk Assessment: Process of evaluating the risk(s) arising from a hazard(s), taking into
account the adequacy of any existing controls, and deciding whether or not the risk(s) is
acceptable.
Senior Management: Person(s) at the highest level of an organization’s structure responsible
for leading, managing and /or directing an organization’s day-to-day activities and/or operations.
Workplace Parties: Includes, but is not limited to, the employer, supervisor(s), workers,
constructor, visitors and owner.
Find out what we can do for you at www.ihsa.ca
Infrastructure Health & Safety Association (IHSA)21 Voyager Court South
Etobicoke, Ontario M9W 5M7 CanadaTel: 1-800-263-5024 • Fax: 905-625-8998
www.ihsa.ca
About IHSA IHSA’s vision is the elimination of all workplace injuries, illnesses, and fatalities within our member firms.
We engage with our member firms, workers, and other stakeholders to help them continuously improve their health and safety performance. We do this by providing effective and innovative sector-specific programs, products, and services.
We offer • Training programs • Consulting services • Health and safety audits • Publications and e-news • Posters and stickers • Reference material • A resource-rich website.
Recommended