Document No.: BULACAN STATE UNIVERSITY (BulSU) BulSU-SP ... · SYSTEM PROCEDURE MANUAL 2 of 21 Tile: Effective Date: CONTROL OF DOCUMENTED INFORMATION March 06, 2017 Revision No.:

BULACAN STATE UNIVERSITY (BulSU)

Document No.:

BulSU-SP-QMS-01Type: Page:

SYSTEM PROCEDURE MANUAL 1 of 21 Tile: Effective Date:

CONTROL OF DOCUMENTED INFORMATION March 06, 2017

Revision No.:

0

Prepared by: Reviewed by: Reviewed by:

DR. ALFREDO G. MENDOZA

QMR/ Director, IQAU

DR. EDGARDO M. SANTOS Vice President for Academic Affairs

DR. TEODY C. SAN ANDRES

Vice President for Executive OperationsReviewed by: Reviewed by: Approved by:

JAIME P. PULUMBARIT

Vice President for Finance, Administration and Resource Generation

DR. CECILIA A. GERONIMO Vice President for Research,

Extension and Training

DR. CECILIA N. GASCON President

This is a controlled documented information and must not be printed and photocopied without permission from the QMR.

1.0 OBJECTIVES

1.1 To establish a procedure for the preparation, identification, distribution and updating of documents relevant to the quality management system (QMS) of Bulacan State University (BulSU).

1.2 To provide guidelines for controlling all QMS documents and data pertinent to operations and services of BulSU.

1.3 To establish and maintain a system for preparing, identifying, collecting, indexing, accessing, filing, storing, maintaining and disposing university records.

2.0 SCOPE 2.1 This procedure includes creation, approval, registration, revision, and distribution of approved new

documents; and retrieval, cancellation and disposition of obsolete/ superseded documents.

2.2 This procedure also covers control of documented information internally-generated by the university and documented information obtained by BulSU from external sources.

3.0 TERMS AND DEFINITIONS 3.1 Active records – records that are currently in-use as immediate reference during performance of

work.

3.2 Addendum – addition or supplement to an existing document.

3.3 Archived records – records that are not actively used but may still be used in the future, and are still within the defined retention period. The storage of these records maybe transferred to another location to avoid congestion in the work area.

3.4 Confidential records – records determined by the QMR/ Deputy QMRs and/ or the Process Owner to contain sensitive information hence the accessibility is restricted.

3.5 Controlled Documented Information – documents which require updating of information, monitoring of distribution/ holder and retrieval when it becomes obsolete and replaced with current version.

3.6 Copyholder – refers to the person/ unit issued with the document.

3.7 DICR – Documented Information Change Request

3.8 Destruction – process of eliminating or deleting records beyond any possible reconstruction.

3.9 Disposition – range of processes associated with implementing records retention, destruction or transfer decisions which are documented in disposition authorities or other instruments.


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3.10 Document – meaningful data and other information and its supporting medium, i.e., procedure, specification, drawing, report, standard, records, etc. The medium could be paper, magnetic, electronic or optical computer disc, photograph or master sample, or a combination thereof. Also, referred to as documented information to be maintained

3.11 Document and Record Custodian (DRC) – function mainly responsible for the control of documents issued by the Document Controller (DC) to the colleges/ offices, including records generated to evidence implementation of the documents.

3.12 Document Controller (DC) – person mainly responsible for the control and maintenance of the management system documents including issuance, revision and distribution.

3.13 Documentation – refers collectively to documents and records necessary for the effective planning and implementation of the management systems. It could also refer to any action to management system documents which includes but not limited to issuance of copy, omission of a document from the documentation, addition of a document, or revision of a document.

3.14 Documentation Team – a group composed of representatives from the different colleges/ offices tasked to prepare and update management system and operational procedures, guidelines and work instruction including where necessary, forms.

3.15 Documented Information – information required to be controlled and maintained by an organization and the medium which it is contained.

3.16 External Documents – documents generated by external parties such as government agencies which are necessary in the implementation and maintenance of the management systems.

3.17 Inactive records – records removed in the active filing but are retained or archived until its defined retention period for future reference or legal purposes.

3.18 Initiator – proponent of the document

3.19 Internal Documented Information – refers to procedures, policies, letters and memos and other documents originating from BulSU.

3.20 Obsolete Documented Information – documents replaced/ removed/ discarded from the implementation of the management system due to modification or as planned.

3.21 Permanent records – records determined by the Management Representative and/ or Process Owner which are to be retained permanently and shall not be subject to destruction.

3.22 Procedure – specified way to carry out an activity or a process. Procedures can be documented or not

3.23 QMR – Quality Management Representative

3.24 QMS – Quality Management System

3.25 Record – special type of document stating results achieved or providing evidence of activities performed. Also, referred to as documented information to be retained.

3.26 Record disposition – means or procedure how records would be destroyed after the defined retention period.


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3.27 Retention period – the period at which a record shall be maintained and /or not to be disposed or destroyed. The retention period of a record starts at the date the record is generated.

3.28 Retention status – either active or inactive and for archiving or disposition

3.29 Uncontrolled documented information – document which is not required to be retrieved and replaced with the current version when it is revised.

4.0 REFERENCES

None


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5.0 DETAILS 5.1 Control of Internal Documented Information (Documents)

ACTIVITY RESPONSIBILITY NOTES/ REFERENCES

Initiator/ ISO Working Team

1. The need for new/ change to documented information may be prompted by among others the following: Changes to the processes, scope of the

management; Results of management system

planning and reviews; Operational/ business/ university need; Corrective action; Applicable customer, statutory,

regulatory and other requirements; and Requirement for documented

procedure needed to control a process

Initiator 2. DICR form (BulSU-SP-QMS-01F1) shall be used to formally process and register the document. Items 2 – 9 of the form shall be accomplished.

Initiator 3. A copy of the proposed documented

information shall accompany the DCR. Guidelines on documented information formatting and coding can be found in Section 5.6 of this procedure. Where necessary, consult with the Document Controller (DC) and Document and Record Custodian (DRC).

Initiator 4. A single DICR may be filed for several

documents with the same reviewing and approving function which are reviewed/ approved at the same time.

Initiator 5. The draft documented information shall be forwarded to DC together with the accomplished DCR for registration

START

Determine need for new/ revision of documented

information

Accomplish Documented Information Change

Request (DICR) form

Forward draft document to DC

A


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DC 6. DICR shall be numbered as follows:

XX-000

Where: XX – last two digits of the calendar year 000 – counting number (maybe re-set at

the start of the year) The DICR shall be registered and monitored using DICR Registration Monitoring Form (BulSU-SP-QMS-01F2).

DC 7. The DCR shall be forwarded to the Reviewing Authority within two (2) working days upon the receipt of the request. Refer to Section 5.7 for the reviewing authority per documented information type/ level.

Reviewing Authority

8. Validity shall be based on the professional judgment of the reviewing function on the necessity/ applicability/ workability and adequacy of the proposed document/ revision to the effectiveness of the management system.

Reviewing Authority

9. The review and evaluation of the proposed document shall be completed within three (3) working days upon receipt of the request. Items 10-11 of the DICR form shall be accomplished. Comments may be written on the draft itself.

DC 10. The DICR shall be forwarded to the

approving authority if the document is recommended for approval; otherwise, the request shall be returned to the Initiator for fine-tuning or cancellation.

A

Register the DICR

Forward to Reviewing Authority

Review and validate the draft documented

information and DICR

Return to Document Controller

B

F


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DC 11. The DICR shall be forwarded to the approving authority within two (2) working days upon receipt from the reviewing authority. Refer to Section 5.4 for the signatories per document type/ level.

YES

NO Approving Authority 12. The evaluation of the request shall be performed within three (3) working days upon receipt of the request from the Document Controller. Items 12-13 of the DICR shall be accomplished.

DC 13. Contents and formats of the document shall be polished. Documented information coding, effective date, pagination and other details shall be put in order.

DC 14. The effective date of the document shall be

preferably within five (5) working days after its approval. Where necessary, discussion with the Initiator may be initiated to determine the practicality of the set effective date. In the event that it is necessary to implement any revision immediately, a documented approval (e.g. minutes, memo, e-mail) shall be issued to justify effective date of documented information to be processed. Revision of the documented information shall be processed within ten (10) working days after issuance of approval.

DC 15. The Master List of Internal Documented

Information (BulSU-SP-QMS-01F3), shall be updated. The Master List shall be maintained in soft copy and shall be uploaded in the designated shared folder, where practicable.

B

Forward to Approving Authority

Finalize documented information

D

Approved? C


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DC 16. A copy of the reviewed/ approved documented information shall be printed and routed for signature. Once signed, the document shall be stamped MASTER COPY at the front page of the document.

DC 17. The Documented Information Issuance

and Revision History (BulSU-SP-QMS-01F4) shall be accomplished.

DC 18. Mark the e-copy of the documented

information as “Original Signed” and upload in the designated folder/ shared folder.

DC 19. The Master Copy of the superseded documented information shall be stamped OBSOLETE on every front page and filed for reference. “Obsolete” stamp shall be dated for immediate reference in archiving and disposal of the said documented information.

DC 20. Obsolete documented information shall be

disposed after 3 years. Obsolete e-copies shall be removed from the designated folder/ shared folder during replacement with the current version.

DC/ DRC 21. Other obsolete hardcopies may be re-used

as scratch paper, provided these are marked or crossed out on the used face.

DC/ DRC 22. Hardcopies shall be reproduced from the Master Copy or printed directly from the designated folder by the DC/ DRC. Each page shall be stamped CONTROLLED COPY and initialed. Issuance of controlled hardcopies shall be recorded in Documented Information Issuance and Retrieval Form (BulSU-SP-QMS-01F5)

D

Prepare and issue final documented information

Retrieve superseded documented information

Where applicable, reproduce and

distribute hardcopies

E


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DC 23. The editable e-copy of the document shall be filed accordingly. The e-copy of the superseded document shall be kept separately by the DC in the designated “Obsolete” folder for reference. Only the e-copies kept by the DC shall be considered official.

MIS Note: The electronic folder shall be

appropriately protected to ensure that the documented information is preserved.

DC / MIS 24. Backup of the electronic management

system files shall be done quarterly. Monitor the back-up of files using Schedule and Monitoring of QMS Documented Information Back-ups (BulSU-SP-QMS-01F6).

DC

NO

YES

Initiator 25. The initiator may make changes/ revisions to the proposed documented information, depending on the comments by the reviewing authority and approving authority.

E

Maintain documented information

END

C

Update Initiator

END

Appealable? F


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5.2 Control of External Documented Information (Documents)


Recipient 1. Management system-related external documented information shall include but not limited to the following: Management system standards and

publications; Copies of applicable laws and

regulations including permits, licenses, etc.;

Equipment manuals; Safety Data Sheet (SDS); and Permits and licenses that relate to the

company’s continuous provision of its services

Recipient 2. The received documented information shall be forwarded to the DC/ DRC for registration immediately, especially those that related to compliance obligations.

DC 3. Assess the relevance and/ importance of the documented information in the effective implementation and maintenance of the management system. Documented information found not relevant shall not be registered.

DC 4. The title and medium used [hardcopy,

electronic] of the received external document shall be indicated in the Master List of External Documented Information (BulSU-SP-QMS-01F7). Other pertinent information such as author or source of the document file shall be indicated, if available.

DC 5. The Master List shall be maintained in soft

copy and shall be uploaded in the designated folder, where practicable.

START

Receive QMS-related external documented

information

Forward to Document Controller

Register the documented information

A


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DC 6. Original hardcopies shall be stamped with “Master Copy” at the front page of the document. Electronic copies shall be filed in the “Controlled External QMS Documented Information” folder.

Note: The electronic folder shall be

appropriately protected to ensure that the documented information is preserved.

DC/ DRC 7. Copies may be reproduced from the original copy or printed from designated folder/ shared folder for distribution to relevant functions.

DC/ DRC 8. Copies of applicable laws and regulations

may be provided to Communication Office for their immediate reference.

DC 9. The Documented Information Issuance and

Retrieval Form (BulSU-SP-QMS-01F5), shall be signed by the copyholders upon receipt and/ or turn-over of the copies of external documented information. Copy Holders of external documented information shall be recorded in the Master List of External Documented Information (BulSU-SP-QMS-01F7).

Copyholder 10. The documented information shall be kept from alteration and unintended use.

DC/ DRC 11. Where applicable, correspondence with the

sources of external documented information shall be maintained to check if there are updates to the documented information.

A

Identify/ Mark/ Upload documented information

Where necessary, distribute external

documented information

Maintain documented information

END


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5.3 Request for Copies of Documented Information


Requestor 1. The form Request for Documented Information (BulSU-SP-QMS-01F8) shall be accomplished to request for copies of internal or external documented information.

DC/ DRC 2. Coding shall be as follows:

YY-000 Where: YY – is the last two digits of the year, 000 – is the series number starting at 001. The series number shall be reset at the start of the year.

DC/ DRC 3. The approving function of the request shall be the Quality Management Representative (QMR) or by the process owner.

QMR 4. The validity of the request shall be

checked. It shall also be decided whether the copy to be provided shall be hard copy or electronic copy and “controlled” or “uncontrolled.”

DC/ DRC 5. If approved, the issuance of requested

copy shall be done within two (2) working days upon receipt of the request. If not approved, the Requestor shall be notified by the DC/ DRC

DC/ DRC 6. The copy to be provided to the Requestor shall be properly marked “Controlled” or “Uncontrolled”. Electronic copies shall be in PDF format, unless otherwise specified, i.e., for revision, for training, etc.

START

Accomplish RDR form

Register RDR

Forward to Approving Function

Validate request

Furnish Requestor

A


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DC/ DRC 7. For “Controlled” documents, applicable Master Lists (BulSU-SP-QMS-01F3, BulSU-SP-QMS-01F7) shall be updated and issuance shall BulSU-SP-QMS-01F5. Should the document be transmitted electronically, the emails/ other records of correspondence shall be saved.

DC/ DRC 8. Superseded copies of controlled

documents shall be retrieved/ turned over to the Document Controller. Uncontrolled copies shall not be updated.

A

Register issuance of document/ record

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5.5 Control of Documented Information to be Retained (Records)


Process Owner

1. Master List of Records (BulSU-SP-QMS-01F9) shall be used. Generation and maintenance of records can be done by different key functions/ process owner, but the designated Document and Record Custodian of the colleges/ offices shall be overall in-charge for the Master List of their respective areas.

DC/ DRC 2. The Master List shall be updated every year.

The updated list shall be forwarded to the Document Controller for consolidation.

DC 3. The Master List may be maintained in electronic form and stored in the designated folder for easy access, but copies may be printed upon request. Printed copies shall be considered uncontrolled.

Initiator 4. Records/ Forms shall be properly accomplished and coded as necessary. The person generating the record shall countersign erasures of data or information in a record media.

DC/ DRC 5. Records shall be properly stored and protected from damage, and that these remain legible and identifiable. To ensure ease of filing, records shall be filed by year and shall be segregated as confidential or non-confidential. Permanent records shall also be filed separately to avoid unintended use or disposal.

DC/ DRC 6. Borrowing of records by other colleges/ office

or process owner shall be covered with appropriately completed and approved Request for Documented Information (BulSU-SP-QMS-01F8)

START

Register in the Master List

Consolidate Master List

Accomplish records

D

File and maintain records

A


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DC/ DRC 7. The general retention period for QMS

records not covered with any legal requirements shall be three (3) years. Records shall remain active for the first year and may be archived (inactive) the year after until its defined retention period. The retention period shall be reflected in the Master List (BulSU-SP-QMS-01F9) NOTE: Records which are not for disposal, retention period shall be reflected as “permanent”.

YES

NO

DC/ DRC 8. Identification and segregation of records shall be done yearly using the records “Filing Year” as the reference period. Culling out of records shall be done preferably within the first quarter of the following year.

DC/ DRC 9. Records in hardcopies for archiving shall be segregated, bundled by year, and labelled with the following information: Colleges/ Department/ Office/ Unit Type of record Year generated Confidential [if the record is confidential]

DC/ DRC 10. Records for archiving to be stored shall be filed in the designated Records Storage Area.

DC/

DRC 11. The Master List of Records shall be updated

accordingly. DC/

DRC 12. Archived records shall be inspected quarterly

to ensure these are appropriately protected from damage or loss. Records Storage Inspection Checklist shall be used (BulSU-SP-QMS-01F10)

A

Prepare records for archiving

Archive files

C

For archiving?

B


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YES

NO DC/ DRC 13. Records due for disposal shall be identified yearly based on the defined retention period in the Master List. Identification of records for disposal may be done simultaneously with the culling of records for archiving. Identified records for disposal shall be re-confirmed by the process owner.

DC/ DRC 14. Records with confidential information shall be shredded first before disposal. If re-used internally, the used side shall be crossed-out to prevent them from unintended use. After which, re-used records shall be disposed properly.

DC/ DRC 15. Retention period of electronic records shall

be defined in Master List of Records. Where applicable, updated List shall be given to Document Controller for consolidation and updating.

C

B

Dispose/ Delete/ Shred

END

For disposal? D


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5.6 Documentation Roles and Responsibilities

DOCUMENT LEVEL RESPONSIBILITY

PREPARED BY REVIEWED BY APPROVED BY

1. Policy Manual (PM) Director, IQAU/ QMR Vice Presidents President

2. System Procedure Manual (SP)

Director, IQAU/ QMR Vice Presidents President

3. Operational Procedures and Work Instructions including Quality Control Plans

Heads of Department/ Office/ Unit

Concerned Vice President

President

Dean of College Vice President for Academic Affairs

5.7 Guidelines in Formatting the Internal Documented Information (Procedure, Guidelines)

5.7.1 The following information at the minimum shall be contained:

5.7.1.1 For levels 1, 2, and 3:

A. First Page

Header

− BulSU logo − Type of Management System Document (PM, SP, OP) − Document Number and Title − Revision Number – the number the document has been revised

and/ or issued; first revision is 0 − Page Number − Effective Date (Month DD, YYYY) − Name and signature of functions in the preparation, review, note

and approval of the document

B. Second page and succeeding pages Header

− BulSU logo − Type of Management System Document − Document Number and Title − Revision Number – the number the document has been revised

and/ or issued; first revision is 0 − Page Number − Effective Date (Month DD, YYYY)

Footer (for all pages) “This is a controlled documented information and must not be printed,

photocopied without prior permission from the QMR.”

5.7.1.2 For forms, letters, memos, the format prescribed by BulSU shall be adopted.


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5.7.2 Forms required by the system and operational procedures shall be of those included in the approved procedures. Nature of revision in the forms shall be logged as well in the same Revision History (BulSU-SP-QMS-01F4) of the procedure from where it is appended.

5.7.3 The contents of documents except for forms and QMS Policy Manual, shall be preferably outlined as follows:

5.7.3.1 System and Operational Procedures

1.0 OBJECTIVES – section indicating the purpose of the document

2.0 SCOPE – section indicating the applicability of the document, i.e., functions, processes and areas covered and limitations of the document

3.0 TERMS AND DEFINITIONS – contains definition of concepts and acronyms introduced/ used in the document to facilitate common and easy understanding among the readers

4.0 REFERENCES – documents used in the development of the procedure as well as procedures/ documents that contain further details in the application/ implementation of certain steps of the procedure

5.0 DETAILS – contains the procedure proper and may be expressed in narrative format, flowcharts, tables, graphs, figures or a combination of these

6.0 ATTACHMENTS – contains additional information

7.0 FORMS – contains listing of forms associated to the procedure

8.0 DOCUMENTED INFORMATION ISSUANCE AND REVISION HISTORY – contains a summary of the issuance and details of revision of the document.

5.7.3.2 Work Instructions

FLOWCHART/ DETAILS FORMS DOCUMENTED INFORMATION ISSUANCE AND REVISION HISTORY

5.7.3.3 Numbering of topics shall be as follows: 1.0 1st line

1.1 2nd line

1.1.1 3rd line

1.1.1.1 4th line

5th line

− 6th line

5.7.4 All documents shall be numbered as follows: BulSU-XX-YYY-00Z0


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Where:

XX - Documentation Level/ Type of document: PM – Policy Manual SP – System Procedures Manual OP – Operational Procedures and Guidelines WI – Work Instructions

YYY - College/ Department/ Office/ Unit to which the document is originating Refer to BulSU Documentation Codes (BulSU-SP-QMS-01A1) for list of codes of different colleges/ departments/ offices/ units

00 - Documentation Series Number, using counting numbers starting from “01.”

Z0 - F0 – Signifies that the document is a form, where it is appended to the procedure to which it is referenced;

- A0 – Signifies that the document is an attachment, where it can be included under the Sub-heading, 6. ATTACHMENTS or appended to the procedure when the content is long and would requires a separate page

- D0 – Signifies that the document is an addendum to the existing document

- 0 – is a counting number

5.7.5 For levels 1, 2, and 3 except for forms and attachments, the paper size shall be A4 (8.27”

x 11.69”). Margins shall be 2 cm left and 2 cm right. Text shall be Arial, font size 10.

5.8 Control of Addendum 5.8.1 Additional provision or “Addendum” to an existing document shall be initiated following

the same procedure for the control of internal documented information (refer to section 5.1) with regard to the use of the DICR, review and approval and uploading and/ or distribution.

5.8.2 The addendum however maybe formatted and issued as a separate documented information from the existing documented information if the reviewing and approving functions from the existing documented information have changed and/ or the contents may result to its repagination/ re-structuring. The addendum shall be coded following the basic code of the existing documented information to which it references with.

5.8.3 The addendum shall be titled as follows:

“ADDENDUM TO <TITLE OF THE DOCUMENTED INFORMATION>

5.8.4 As a separate documented information, the addendum shall be controlled as a separate document, i.e., own Revision No, Effective Date and Revision Issuance and Revision History


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5.9 Documented information other than management system documents

5.9.1 Other documented information that may be developed outside of the management system

documentation shall bear the following, at the minimum: 5.9.1.1 Title 5.9.1.2 Revision status/ version/ date 5.9.1.3 Pagination 5.9.1.4 Author/ Owner 5.9.1.5 Approval

5.9.2 The documented information shall be likewise subjected to applicable documented information control procedures and guidelines.

5.10 Maintenance and distribution of management system documents

5.10.1 Management system documents shall be uploaded in the designated folder/ shared folder, and shall be maintained by the Document Controller (DC). Only the DC can upload and effect revision on the document. Uploaded documents shall be watermarked as “CONTROLLED COPY”. All employees are to use only the “CONTROLLED” copies as reference in the performance of their work.

5.10.2 Controlled copies shall be provided to work stations where there is no or limited access to the electronic management system documentation. Hardcopies shall be reproduced from the Master Copy or directly printed from the designated folder/ shared folder by the DC.

5.10.3 Printing or e-copying of uploaded documents is restricted and must be appropriately permitted. To request for an access or a copy, BulSU-SP-QMS-01F8, Request for Documented Information form shall be used and coordinated with the DC or with the designated DRC, and approved by the QMR.

5.10.4 Electronic copies may be provided by the DC to Requestor with appropriately approved Request. The copies shall be watermarked UNCONTROLLED by the DC. Only the DC can issue electronic copies.

5.10.5 Photocopies other than those authorized by the QMR and/ or not appropriately stamped as CONTROLLED are unofficial copies and are automatically considered UNCONTROLLED. Uncontrolled documents shall not be updated.

5.10.6 Copies may be reproduced by the DC/ DRC for purposes of revision or as reference materials for training purposes and auditing activities. Such copies shall also be considered UNCONTROLLED. The Request for Documented Information form (BulSU-SP-QMS-01F8) shall be initiated but the Documented Information Issuance and Retrieval Form (BulSU-SP-QMS-01F5) shall not be accomplished anymore.

5.10.7 The management system documents are classified as for Internal Use; therefore, access (viewing rights) of external parties to these documents is restricted and where necessary, appropriately authorized. Management system documents provided to external interested parties shall be UNCONTROLLED and shall be marked as such.


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5.11 Control of Electronic Documents 5.11.1 Printing of management system documents from the designated folder/ shared folder is

discouraged. Printouts from any workstations other than those by the DC/ DRC are considered uncontrolled and unofficial, and therefore shall not be used as reference in the implementation of the management system.

5.11.2 Changes to document which are limited to page format without change in the contents of the document need not be reviewed and re-approved. Hence, reformatting of the document may be effected immediately in the e-copy and uploaded accordingly in the designated folder without change in its Effective Date and Revision No. In support of BulSU’s initiatives to save on paper, the issued controlled hardcopies including the Original Copy of reformatted document may be retained until revision of its contents becomes necessary or until the document is due for its every two (2) review.

5.11.3 Confidential or classified documented information shall be segregated and protected with passwords, as appropriate. Only authorized personnel shall be given access to such documented information.

5.11.4 Obsolete documented information shall be removed from the designated folder/ shared folder permanently. The DC/ DRC is tasked to ensure that obsolete electronic copies are securely deleted from the designated folder. The e-copy of the superseded document shall be kept in the designated “Obsolete” folder for reference. The editable e-copy of the document shall be filed accordingly. Only the e-copies kept by the DC/ DRC shall be considered official.

5.11.5 Back up copy of the management system documentation shall be maintained in separate hard disks or other appropriate media.

6.0 ATTACHMENTS 6.1 BulSU-SP-QSM-01A1, BulSU College/ Department/ Office Codes

7.0 FORMS

7.1 BulSU-SP-QMS-01F1, Documented Information Change Request (DICR)

7.2 BulSU-SP-QMS-01F2, DICR Registration and Monitoring Form

7.3 BulSU-SP-QMS-01F3, Master List of Internal Documented Information

7.4 BulSU-SP-QMS-01F4, Documented Information Issuance and Revision History

7.5 BulSU-SP-QMS-01F5, Documented Information Issuance and Retrieval

7.6 BulSU-SP-QMS-01F6, Schedule and Monitoring of QMS Documented Information Backup

7.7 BulSU-SP-QMS-01F7, Master List of External Documented Information

7.8 BulSU-SP-QMS-01F8, Request for Documented Information

7.9 BulSU-SP-QMS-01F9, Master List of Records


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7.10 BulSU-SP-QMS-01F10, Records Storage Inspection Checklist

DOCUMENTATION CODES

BulSU-SP-QMS-01A1 Page 1 of 2 Revision: 0

CODE COLLEGE/ DEPARTMENT/ OFFICE/ UNIT

ACADEMIC AFFAIRS

Colleges

CAFA – College of Architecture and Fine Arts CAL – College of Arts and Letters CBA – College of Business Administration CCJE – College of Criminal Justice Education CHE – College of Home Economics CICT – College of Information and Communication Technology CIT – College of Industrial Technology COE – College of Engineering CoEd – College of Education COL – College of Law CON – College of Nursing CS – College of Science

CSSP – College of Social Science and Philosophy GS – Graduate School

IPERS – Institute of Physical Education, Recreation and Sports ILGA – Institute of Local Government SWI – Sentro ng Wika LHS – Laboratory High School

DI – Dean of Instruction

NSTP – National Service Training Program RegO – Registrar’s Office LIB – Library Services

Student Affairs

SA – Student Affairs SWE – Student Welfare GC – Guidance Center SI – Student Internship

PESO – Public Employment Service Office SD – Student Development

OSO – Office of the Student Organization OSPI – Office of Student Publications and Information CAAO – Culture and the Arts Affairs Office

SS – Student Services AdO – Admissions Office SCIO – Socio-Community Development SCO – Scholarship Office

EXECUTIVE OPERATIONS

AA – Alumni Affairs CAO – Community Affairs Office CG – Communications Group

FTDU – Full Time Delivery Unit GAD – Gender and Development

IA – International Affairs

DOCUMENTATION CODES


CODE COLLEGE/ DEPARTMENT/ OFFICE/ UNIT

MEO – Monitoring and Evaluation Office MIS – Management Information System

OFSD – Office of the Faculty and Staff Development Program PD – Planning and Development

PMO – Project Management Office QA – Quality Assurance

FINANCE, ADMINISTRATION AND RESOURCE GENERATION

AUX – Auxiliary BC – Business Center

CAN – Canteen DO – Dormitory FS – Food Services HO – Hostel

FO – Finance AO – Accounting Office BO – Budget Office CO – Cashier’s Office

ADM – Administration

BGMO – Building and Ground Management Office FMO – Facility Management Office

HRMO – Human Resource Management Office MU – Medical Unit PU – Procurement Unit RO – Records Office

SPO – Supply and Property Office SU – Security Unit

RESEARCH, EXTENSION AND TRAINING

TO – Training Office CLIP – Center for Learning and Innovation for Professionals

EO – Extension Office IEG – Institute of Environmental Perforamnce

SEEK – Sentro ng Edukasyon para sa Ekonomiya at Kalikasan

ResO – Research Office CBS – Center for Bulacan Studeies

CIRPS – Center for Inter-Institutional Policy Research Students FTL – BulSU-DOST Food Testing Laboratory ITSO – Innovation and Technical Support Office

DOCUMENTED INFORMATION CHANGE REQUEST (DICR)

BulSU-SP-QMS-01F1 Page 1 of 1 Revision: 0

1. DCR No. 2. Initiator:

(Signature Over Printed Name) 3. Nature of Change: 4. College/ Office/ Unit: 5. Date:(mm/dd/yy)

New

Revision

Deletion/ Obsolete

Description of Documented Information 6. Documented

Information No: 7. Documented Information Title: 8. Documented Information Type:

Policy Procedure Form Attachment

Others (Please specify)

9. Description & Purpose of Documentation Request :(Provide additional sheet if necessary)

10. Proposed Effective Date: (mm/dd/yy)

To be accomplished by the Reviewing Authority. Kindly return the draft & updated request to the Document Controller within 5 working days upon receipt.

11. Review of Documented Information Change Request (Attach supporting documents, if any.)

12. Action Taken/ Disposition: Recommended for: Approval Disapproval For Fine-tuning

Reviewed by:

Date:

(Signature Over Printed Name)

To be accomplished by the Approving Authority. Kindly return the draft & updated request to the Document Controller within 5 working days upon receipt.

13. Action Taken/ Disposition:

Approved Disapproved For Fine-tuning

14. Remarks, if any:

Approved by:

Date:

(Signature Over Printed Name)

To be accomplished by the Document Controller

15. Update QMS

Actions (where applicable) Date Signature Remarks

Revision History Updated

Master Lists Updated

Uploaded/ Distributed

Obsolete Copy Retrieved/ Deleted

DCR REGISTRATION AND MONITORING FORM


DCR NO DATE RECEIVED

(mm/dd/yy) DOC NO/ DOC TITLE

REQUESTED BY

ACTION TAKEN DATE

COMPLETED (mm/dd/yy)

MASTER LIST OF INTERNAL DOCUMENTED INFORMATION


As of ____________

NO DOCUMENT NUMBER DOCUMENT TITLE INITIAL ISSUANCE CURRENT REVISION

REV PAGES EFFECTIVE

DATE REV PAGES

EFFECTIVE DATE

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

DOCUMENTED INFORMATION ISSUANCE AND REVISION HISTORY


Doc No & Title:

REV DATE (mm/dd/yy)

REV PAGE

REVISED DESCRIPTION OF ISSUANCE/ REVISION EFFECTIVE

(mm/dd/yy)

DOCUMENTED INFORMATION ISSUANCE AND RETRIEVAL


Doc. No. Title:

RDR NO

EFFECTIVE DATE

REV

ISSUANCE RETRIEVAL

NAME DATE SIGNATURE

OF COPY HOLDER NAME

DATE SIGNATURE

OF COPY HOLDER

SCHEDULE AND MONITORING OF QMS DOCUMENTED INFORMATION BACKUP


MANAGEMENT SYSTEM DOCUMENTS YYYY

Q1 Q2 Q3 Q4

1. QMS POLICY MANUAL 2. SYSTEM PROCEDURES

a. b. c. d. e.

3. OPERATIONAL PROCEDURES A. Colleges

a. b. c.

B. Offices a. b. c.

C. D.

4. RECORDS, LIST, PLANS AND PROGRAMS

Done by: Verified by:

Note: The actual date of back-up of the documented information shall be indicated

MASTER LIST OF EXTERNAL DOCUMENTED INFORMATION


As of___________

NO REG DATE (mm/dd/yy)

DOCUMENT TITLE SOURCE/ AUTHOR FORM (E/ P)

ISSUE/ PUBLICATION

YEAR 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

LEGENDS: E – Electronic copy P – Printed copy

REQUEST FOR DOCUMENTED INFORMATION

CUT HERE

REQUESTOR DATE: RDR NO:

COLLEGE/ OFFICE NO OF COPIES:

Description of Requested Documented Information

DOC/ RECORD NO: TITLE:

PURPOSE:

Requested by: Approved by:

Signature over Printed Name Signature over Printed Name

Designation:

Date:

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To be accomplished by the Requestor To be accomplished by the Approving Function

Hard Copy Electronic Copy Controlled Uncontrolled


REQUEST FOR DOCUMENTED INFORMATION

REQUESTOR DATE: RDR NO:

COLLEGE/ OFFICE: NO OF COPIES:

Description of Requested Documented Information

DOC/ RECORD NO: TITLE:

PURPOSE:

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Date:

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To be accomplished by the Requestor: To be accomplished by the Approving Function

Hard Copy Electronic Copy Controlled Uncontrolled


MASTER LIST OF RECORDS


COLLEGE/ DEPARTMENT/ OFFICE: As of:

RECORD/ FILE CODE

RECORD/ FILE NAME FORMAT

(E/P) TYPE (C/NC)

ACTIVE PERIOD

(Yrs)

ACTIVE LOCATION

RET’N PERIOD

(Yrs)

ARCHIVE LOCATION

REMARKS

LEGENDS: E – Electronic copy P – Printed C – Confidential NC – Not Confidential

RECORDS STORAGE INSPECTION CHECKLIST


Instruction: Indicate in the applicable column (Q1, Q2, Q3, Q4) the physical condition of stored records during inspection: OK – Good: labels intact/ readable; box/ container/ rack is reasonably in good condition; no sign of damage or X – Not Good: labels defaced/ not readable; box/ container/ rack is reasonably not in good condition; sign of damage/ deterioration

RECORD FILE/ BUNDLE TITLE DATE/ STATUS

Q1 Q2 Q3 Q4

Inspected by (Countersigned)


Document No.:

BulSU-SP-QMS-02 Type: Page:


RISKS AND OPPORTUNITIES ASSESMENT (ROA) March 06, 2017

Revision No.:

0



QMR/ Director, IQAU

DR. EDGARDO M. SANTOS

Vice President for Academic Affairs



JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To define the process for establishing, implementing and maintaining the process of identification, evaluation, action planning for risks and opportunities that need to be addressed to:

1.1.1 Give assurance that the QMS can achieve its intended results;

1.1.2 Enhance desirable effects;

1.1.3 Prevent, or reduce, undesired effects; and

1.1.4 Achieve continual improvement.

2.0 SCOPE 2.1 This process is applicable to risks and opportunities associated to BulSU’s internal and external

issues, needs and expectations of interested parties, and business processes.

3.0 TERMS AND DEFINITIONS

3.1 Interested party – person or organization that can affect, be affected by, or perceive itself to be

affected by a decision or activity, i.e., customers, communities, suppliers, regulators, non-governmental organizations, investors, employees, etc

3.2 Residual Risk – risk remaining after risk treatment; can also be known as “retained risk”

3.3 Risk – effect of uncertainty; combination of the consequences of an event and the associated “likelihood” of occurrence.

3.4 Risks and Opportunities – potential adverse effects (threats) and potential beneficial effects (opportunities)

3.5 Risks and Opportunities Assessment (ROA) - process of identifying, evaluating and action planning for risks and opportunities taking into consideration the internal/ external issues and needs and expectations of interested parties and business processes.

3.6 Risk Treatment – process to modify risk, it can involve the following:

3.6.1 Avoiding the risk by deciding not to start or continue with the activity that gives rise to the risk;

3.6.2 Taking or increasing risk in order to pursue an opportunity


Document No.:



RISKS AND OPPORTUNITIES ASSESSMENT (ROA) March 06, 2017

Revision No.:

0


3.6.3 Removing the risk source

3.6.4 Changing the likelihood

3.6.5 Changing the consequences

3.6.6 Sharing the risk with another party or parties (including contracts and risk financing); and

3.6.7 Retaining the risk by informed decision

3.7 Uncertainty – state, even partial, of deficiency of information related to, understanding or knowledge of, an event, its consequence, or likelihood.

4.0 REFERENCES

4.1 BulSU-SP-QMS-03, Setting-Up, Review and Renewal of Quality Objectives and Programs


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0


START

5.0 DETAILS


QMR 1. Each department/ section shall be represented in the team. The ROA Team shall be given orientation on the ROA process and the use of the ROA Worksheets.

ROA Team 2. The following shall be considered when establishing/ fine-tuning the ROA Worksheet − Description of Risk − Occurrence Rating − Severity Rating − Degree of Control Rating − Risk Score − Risk Rating − Description of Opportunity − Opportunity Analysis − Opportunity Score − Opportunity Rating − Risk and Opportunity Assessment − Risk Treatment Action Plan − Contingency Action Plan

ROA Team 3. The following forms shall be accomplished respectively: − Risk and Opportunity Assessment for

Organization’s Context (BulSU-SP-QMS-02F1)

− Risk and Opportunity Assessment for Needs and Expectations of Interested Parties (BulSU-SP-QMS-02F2)

− Risk and Opportunity Assessment for Business Process (BulSU-SP-QMS-02F3)

ROA Team 4. Column D shall be accomplished. The process of identification of risk shall include finding, recognizing and describing the risks. Risk sources, events, their causes and their potential consequences shall be considered in identifying the risk.

B

Identify risk

A3 A2 A1

Establish/ Fine-tune ROA Worksheet

Form the ROA Team


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0



ROA Team 5. Occurrence rating of the risk event associated to the internal and external issues in Column E shall be 1,2,3,4 or 5, with 1 being unlikely (rare) to occur and 5 being very frequent (almost certain). Refer to Part I, Table A - Occurrence Rating of ROA Criteria (BulSU-SP-QMS-02A1)

ROA Team 6. Severity rating of the risk event associated to the internal and external issues in Column F shall be 1,2,3,4 or 5, with 1 being slight (very low) and 5 being catastrophic (very high). Refer to Table B, Severity Rating of ROA Criteria.

ROA Team 7. Degree of control rating for the occurrence of the risk event and/ or the severity of consequences in Column G shall be 1,2,3,4 or 5, with 1 being avoidable and 5 being highly uncontrollable. Refer to Table C, Degree of Control Rating ROA Criteria.

ROA Team 8. Risk Score [RS] in Column H is determined using the following equation: RS = Occurrence X Severity X Control Refer to Part 3, Risks and Opportunities Assessment Matrix of ROA Criteria., for an overview of the interrelation of occurrence, severity and control.

Green Orange Red

ROA Team 9. The risk score shall determine the overall risk rating for the risk event in Column I as follows: − Green: (1 < RR < 27) – Low Risk − Orange: (28 < RR < 64) – Moderate

Risk − Red: (RR ≥ 65) – High Risk Refer to Part 3, Risk Rating of, ROA Criteria.

C

Perform risk assessment

Determine the degree of control rating

Determine the severity rating

Determine the occurrence rating

B


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ROA Team 10. Risk treatment action plan shall be identified in Column J for Moderate Risk or High Risk after the initial risk assessment. Where appropriate, improvements to existing controls or programs that shall reduce the risk rating of the risk event to acceptable levels shall be determined. (e.g., practicable/ prescribed controls which are not yet implemented)

ROA Team 11. The risk event shall undergo risk

assessment in Columns K, L and M (Refer to Item 5, 6 and 7) to determine the residual risk rating in Column N after the identification of risk treatment action plan. (Refer Item 9)

ROA Team 12. Contingency plan shall be determined in

Column P if the risk rating of the risk event is still Moderate Risk or High Risk after the determination of residual risk rating and identification of risk treatment action plan. Identified plans shall form part of the objectives and programs.

ROA Team 13. Column Q shall be accomplished.

Complete description of the opportunity shall be determined

ROA Team 14. Column R to Column AA shall be

accomplished. Refer to Part 2, Opportunity Assessment Criteria of ROA Criteria.

ROA Team 15. Opportunity Score [OS] in Column AB is

determined using the following equation: OS = Sum of Column K to Column T Refer to Part 3, Risks and Opportunities Assessment Matrix of ROA Criteria.

D

C

Identify risk treatment action plan

Identify opportunity

Analyze opportunity

Perform opportunity assessment

Determine residual risk rating

Determine contingency plan


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0



Green Orange Red

ROA Team 16. The opportunity score shall determine the overall opportunity rating in Column AD as follows: − Green: (OR ≥ 90) – Excellent

Opportunity − Orange: (60 < OR < 89) – Fair

Opportunity − Red: (30 < OR < 59) – Poor

Opportunity Refer to Part 3, Opportunity Rating of ROA Criteria.

ROA Team 17. Actions to address the results of the risk

and opportunity assessment in Column W shall be in A1, A2, A3, B1, B2, B3, C1, C2 and C3. Refer to Part 3, Risks and Opportunities Assessment Matrix of ROA Criteria.

ROA Team 18. ROA Worksheet shall be reviewed and

where necessary, updated as need arises in light of: − New processes/ products/ services − Modification/ relay outing/ renovation − Occurrence of incident or emergency − Management directive − Changes to management system

requirements or scope − New or amendment in applicable

compliance obligations − Changes to internal/ external issues

and needs and expectations of interested parties

END

D

Perform risk and opportunity assessment

Review and update ROA


Document No.:




Revision No.:

0



Document No.:




Revision No.:

0



A. ROA for Organization’s Context(Internal and External Issues)

ROA Team 1. ROA for Organization’s Context worksheet (BulSU-SP-QMS-02F1) shall be used. Internal and external issues of BulSU that can affect its ability to achieve the intended results of the QMS shall be identified in Column B.

2. Internal issues could include:

− Conditions of the organization such as its activities, products and services, strategic direction, culture and capabilities (i.e., people, knowledge, processes, systems) that can represent a strength or weakness of the organization.

3. External issues could include:

− Cultural, social, political, legal, regulatory, financial, technological, economic, natural and competitive circumstances, whether international, national, regional or local.

ROA Team 4. Column C shall be accomplished. The existing controls which specifically manage the issue shall be listed. These shall include among others policies, programs, documented procedures, installations, etc.

C

Describe the existing controls/ mitigating measure/ relevant

programs

Identify internal and external issues

A1


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B. ROA for Needs and Expectations of Interested Parties

ROA Team 1. ROA for Needs and Expectations of Interested Parties worksheet (BulSU-SP-QMS-02F2) shall be used. Internal and external interested parties that may be relevant in their respective departments/ areas shall be identified in Column B. Interested parties may include among others the following: Customers Shareholders Competitors External providers Nearby community

ROA Team 2. Column C shall be accomplished. The

needs and expectations of relevant interested parties shall be identified. The identified needs and expectations of relevant interested parties shall be: Those that are obligatory (mandatory

requirements such as applicable laws, regulations and corporate mandates.

Those that organization voluntarily agrees to comply with such as organizational & industry standards, contractual relationships, codes of practice and agreements with community or NGOs

C

Identify interested parties

A2

Determine the needs and expectations of interested parties


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C. ROA for Business Process

ROA Team 1. Risks and Opportunities Assessment for Business Process worksheet (BulSU-SP-QMS-02F3) shall be used. Business processes (core and support) of BulSU that can affect the ability to achieve the intended results of the QMS shall be identified in Column B.

ROA Team 2. Column C shall be accomplished. The process requirements of the business process shall be identified.

6.0 ATTACHMENTS

6.1 BulSU-SP-QMS-02A1, ROA Criteria

7.0 FORMS

7.1 BulSU-SP-QMS-02F1, ROA for Organization’s Context

7.2 BulSU-SP-QMS-02F2, ROA for Needs and Expectations of Interested Parties

7.3 BulSU-SP-QMS-02F3, ROA for Business Processes

C

Identify process requirements

List down business processes

A3

RISKS AND OPPORTUNITIES ASSESSMENT (ROA) CRITERIA


PART 1 - RISK ASSESSMENT

Risk = Occurrence X Severity X Degree of Control

A. Occurrence Rating

Qualitative Rating Description

Unlikely (Rare) 1 The risk event is not expected to occur in the life of the BulSU The risk event has not occurred for more than 5 years

Occasional (Unlikely) 2 The risk event could possibly occur within 5-year period The risk event has occurred once in 5 years

Moderately Frequent (Possible)

3 The risk event could possibly occur within 3-year period The risk event has occurred once in 3 years

Frequent (Likely) 4 The risk event could possibly occur within 1 year period

The risk event has occurred once during the year

Very Frequent (Almost Certain)

5 The risk event could possibly occur within 6-month period The risk event has occurred more than once during the year



B. SEVERITY RATING

QUALITATIVE RATING DESCRIPTION

Slight (Very Low) 1 Adverse impact to product/ service conformity is contained internally/ no effect on external customer satisfaction Risk event could result to any or combination of the following: breach of BulSU’s plan/ program/ schedule/ procedure negligible cost (less than or equal to PhP 100,000) first aid treatment/ discomfort/ irritating did not result to a valid interested party complaint (e.g., customer,

community, external provider, tenants, etc) image is not affected; employees’ complaint and dealt with

internally brief disruption but no stoppage/ shutdown of operation

Minor (Low) 2 Adverse impact to product/ service conformity has reached an external

customer/ adverse effect on the satisfaction of an external customer Risk event could result to any or combination of the following: breach of corporate directive/ requirement/ policy minimal cost (more than PhP 100, 000 but less than or equal to

PhP 1 million) medical treatment/ acute/ chronic diseases (non-deadly) affecting

single person resulted to one valid interested party complaint (e.g., customer,

community, external provider, tenants, etc) minor embarrassment to the BulSU; adverse publicity in the local

media work stoppage lasting one day

Serious (Medium) 3 Adverse impact to product/ service conformity has reached external

customers/ adverse effect on the satisfaction of more than one external customers Risk event could result to any or combination of the following: breach of agreement/ contract/ understanding with external

interested parties medium financial loss (more than PhP 1 million but less than or

equal to PhP 3 million) lost time accident (no fatality)/ acute/ chronic diseases (non-

deadly) affecting more than 1 person Resulted to more than one valid interested party complaint (e.g.,

customer, community, external provider, tenants, etc) with the same issue

short term damage to BulSU’s reputation; adverse publicity in the regional media

work stoppage lasting more than 1 day



B. SEVERITY RATING

QUALITATIVE RATING DESCRIPTION

Major (High) 4 Adverse impact to product/ service conformity has reached external customers resulting to loss of business/ adverse effect on the satisfaction of more than one external customers Risk event could result to any or combination of the following: short-term breach of statutory requirement significant financial loss (more than PhP 3 million but less than or

equal to PhP 5 million) loss of human life (single fatality)/ acute/ chronic diseases (deadly)

affecting single person loss of business with an interested party (e.g., customer,

community, external provider, tenants, etc) long term damage to BulSU’s reputation; adverse publicity in the

national media suspension of operation for definite period

Catastrophic (Very High)

5 Damage/ loss to the BulSU is practically irreversible Risk event could result to any or combination of the following: multiple/ prolonged breaches of statutory requirements financial loss of more than PhP 5 million multiple loss of human life (multiple fatality)/ acute/ chronic

diseases (deadly) affecting more than 1 person loss of multiple business with interested party (e.g., customer,

community, external provider, tenants, etc) irreparable damage to BulSU’s reputation; adverse publicity in the

international community suspension of operation for indefinite period or closure of the

BulSU



C. DEGREE OF CONTROL RATING (Occurrence of the risk event and/ or the severity of consequences)

Qualitative Rating Description

Avoidable 1 Fully controllable and can be fully avoided by BulSU existing control/ mitigating measures are proven effective risk source can be eliminated by BulSU, i.e., process can be modified/

transferred/ relocated; material can be substituted

Highly controllable 2 Highly controllable by BulSU and partly avoidable through selected risk mitigation actions taken existing control/ mitigating measures are optimum as practicable risk source is within the BulSU’s control, i.e., process is performed on-

site; material is supplied/ decided by BulSU

Moderately controllable

3 Slightly controllable by BulSU but can be influenced by BulSU to a large degree existing control/ mitigating measures are adequate but can still be

improved risk source is originating externally, i.e., process is performed by

external provider off-site; material is supplied/ decided by the customer; natural calamities

Uncontrollable 4 Uncontrollable by BulSU but can be influenced by BulSU to a small

degree existing control/ mitigating measures are barely adequate BulSU has no authority over risk source but risk source is relevant

interested party

Highly uncontrollable 5 Uncontrollable by BulSU and cannot be influenced by BulSU no existing control/ mitigating measures BulSU has no authority over risk source and risk source is not a

relevant interested party



PART 2 – OPPORTUNITY ASSESSMENT (BASIS OF SCORING)

Key Indicator IMPORTANCE (I)/ Weight

FEASIBILITY Opportunity Score (I X F) 1 2 3 4

STRATEGIC DIRECTION Relevance of opportunity (aspect/ issue/ obligation) to BulSU’s strategic directions (vision/ mission)

5 No relevance to strategic direction of BulSU

Relevant to one (1) of BulSU’s strategic directions

Relevant to two (2) of the BulSU’s strategic directions

Relevant to three (3) or more of the BulSU’s strategic directions

COMPLIANCE OBLIGATION What is the effect to compliance obligation?

5 Not related to any compliance obligation

Will fulfil internal requirement

Will fulfil industry (academic institutions) and other external interested parties’ requirements

Will fulfil legal obligations

PRODUCT/ SERVICE QUALITY/ CUSTOMER SATISFACTION What is the impact to product/ service quality and customer satisfaction?

5 No impact in the enhancement of product or service quality or customer satisfaction

Indirect effect in the enhancement of customer satisfaction/ product and/ or service quality

Direct impact in the enhancement of product or service quality or customer satisfaction

Direct impact in the enhancement of product or service quality and customer satisfaction

COST OF IMPLEMENTING THE ACTION What is the estimated cost of implementing the action?

2 More than PhP1M

Greater than 500,000 pesos but less than PhP1M

Greater than 50,000 pesos but less than 500,000

50,000 pesos or less/ No cost

COST OF MAINTAINING THE ACTION

2 Greater than 500,000 pesos per year

Greater than 50,000 pesos but less than

50,000 pesos or less per year

No maintenance cost



Key Indicator IMPORTANCE

(I)/ Weight

FEASIBILITY Opportunity Score (I X F) 1 2 3 4

What is the estimated cost of maintaining the action?

500,000 pesos per year

RETURN OF INVESTMENT What is the Return of Investment of the action (tangible)?

2 ROI is more than 5 years or no tangible return

ROI is more than 3 years but less than 5 years

ROI is 1 to 3 years ROI is less than one year

IMAGE/ BRAND What is the added value to BulSU’s image/ brand?

3 Local Regional/ Provincial National International

MANPOWER UTILIZATION What impact will this action have on the BulSU manpower resources?

1 Action will require additional foreign external provider, different from existing in-house external provider

Action will require additional local external provider, different from existing in-house external provider

Action will require additional in-house manpower resources

Action will make use of existing in-house manpower resources

AVAILABILITY OF RAW MATERIAL/ EQUIPMENT/ SERVICE What is the availability of raw materials/ equipment?

2 Raw material/ equipment/ service needs to be procured outside Asian countries

Raw material/ equipment/ service needs to be imported within Asian countries

Raw material/ equipment/ service needs to be procured locally

Raw material/ equipment/ service is currently available in BulSU

BENEFICIARIES OF ACTION Who are the direct beneficiaries of the action?

3 No direct beneficiary Limited to selected area/ department of BulSU

BulSU-wide BulSU and immediate community or customer



PART III – RISK AND OPPORTUNITIES ASSESSMENT MATRIX

Opportunity Assessment

90-120 Excellent

A1 Low Risk/ Excellent

Opportunity

B1 Moderate Risk/

Excellent Opportunity

C1 High Risk/

Excellent Opportunity

60-89 Fair

A2 Low Risk/

Fair Opportunity

B2 Moderate Risk/ Fair

Opportunity

C2 High Risk/

Fair Opportunity

30-59 Poor

A3 Low Risk/ Poor

Opportunity

B3 Moderate Risk/

Poor Opportunity

C3 High Risk/

Poor Opportunity

1-27 Low

28-64 Moderate

65-125 High

Risk Assessment

LEGENDS: A1 Pursue opportunity, no RTAP required A2 Top Management to decide whether or not to pursue opportunity, no RTAP required A3 Do not pursue opportunity, no RTAP required

B1 Pursue opportunity but needs RTAP aimed at least to reduce likelihood of the risk event occurring and/ or mitigate the adverse impact

B2 RTAP required and Top Management to decide whether or not to pursue opportunity B3 Do not pursue opportunity but needs RTAP aimed at least to reduce likelihood of the risk

event occurring and/ or mitigate the adverse impact C1 Pursue opportunity but implement RTAP aimed at avoiding the risk/ eliminating the risk

source C2 RTAP required aimed at avoiding the risk/ eliminating the risk source and Top Management

to decide whether or not to pursue opportunity C3 Do not pursue opportunity but implement RTAP aimed at avoiding the risk/ eliminating the

risk source



Note:

Opportunity Assessment Range of Score

Range =

= 30

Poor = [lower limit: lowest possible score (30)] – [upper limit: lower limit (30) + range (30) – 1] = 30-59

Fair = [lower limit: preceding upper limit (59) + 1] – [upper limit: lower limit (60) + range (30) – 1] = 60-89

Excellent = [lower limit: preceding upper limit (89) + 1] – [highest possible score (120)] = 90-120

Risk Assessment Range of Score

Low = [lower limit: lowest possible score (1)] – [upper limit: mid score for occurrence (3), severity (3) and control (3)] = 1 - 27

Moderate = [lower limit: preceding upper limit (27) + 1] – [upper limit: 1 level higher of mid score for occurrence (4), severity (4) and control (4) – 1] = 28-64

High = [lower limit: preceding upper limit (64) + 1] – [highest possible score (125)] = 65-125



Risk Rating

Risk Rating Action

GREEN (1 < RR < 27) – Low Risk

A

Risk is acceptable, no further action needed Retain risk by informed decision Take the risk in order to pursue an opportunity

ORANGE (28 < RR< 64) – Moderate

Risk B

Risk can be tolerated but needs risk treatment action plan aimed at least to reduce likelihood of the risk event occurring and/ or mitigate the adverse impact

Transfer/ share the risk

RED (RR ≥ 65) – High Risk

C

Risk is not acceptable; needs risk treatment plan aimed at avoiding the risk/ eliminating the risk source − Stop or suspend work/ operation until risk treatment plan has been

implemented

Opportunity Rating

Opportunity Rating Action

GREEN (OR ≥ 90) – Excellent

Opportunity 1

Opportunity shall be pursued immediately

ORANGE (60 < OR < 89) – Fair

Opportunity 2

Management to decide whether to pursue opportunity

RED (30 < OR < 59) – Poor

Opportunity 3

Opportunity shall not be pursued



Risk Rating (Occurrence Rating X Degree of Control Rating X Severity Rating)

Occurrence Rating Degree of Control

Rating Severity Rating 1

Rare 2

Unlikely 3

Moderate 4

Likely

5 Almost Certain

1 2 3 4 5 1

Avoidable

1 Slight

(Very Low)

2 4 6 8 10 2

High Controllable

3 6 9 12 15 3

Moderately Controllable

4 8 12 16 20 4

Uncontrollable

5 10 15 20 25 5

Highly Uncontrollable

2 4 6 8 10 1

Avoidable

2 Minor (Low)

4 8 12 16 20 2

High Controllable

6 12 18 24 30 3


8 16 24 32 40 4

Uncontrollable

10 20 30 40 50 5


3 6 9 12 15 1

Avoidable

3 Serious (Medium)

6 12 18 24 30 2

High Controllable

9 18 27 36 45 3


12 24 36 48 60 4

Uncontrollable

15 30 45 60 75 5


4 8 12 16 20 1

Avoidable

4 Major (High)

8 16 24 32 40 2

High Controllable

12 24 36 48 60 3


16 32 48 64 80 4

Uncontrollable

20 40 60 80 100 5


5 10 15 20 25 1

Avoidable

5 Catastrophic (Very

High)

10 20 30 40 50 2

High Controllable

15 30 45 60 75 3


20 40 60 80 100 4

Uncontrollable

25 50 75 100 125 5


RISKS AND OPPORTUNITIES ASSESSMENT (ROA) - ORGANIZATION'S CONTEXT

As of <Month DD, YYYY>

OC

CU

RR

EN

CE

SE

VE

RIT

Y

CO

NT

RO

L

RSRISK

RATING

OC

CU

RR

EN

CE

SE

VE

RIT

Y

CO

NT

RO

L

RSRESIDUAL

RISK LEVEL

0 N/A 0 N/A

0 N/A 0 N/A

0 N/A 0 N/A

0 N/A 0 N/A

0 N/A 0 N/A

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0 N/A 0 N/A

0 N/A 0 N/A

0 N/A 0 N/A

0 N/A 0 N/A

NO ISSUES DESCRIPTION OF RISK

RESIDUAL RISK

RISK TREATMENT ACTION PLAN

(only for Moderate to High Risk)

CONTINGENCY PLAN(for Moderate to High Risk after

RTAP)

RISK ASSESSMENT

EXISTING CONTROLS/ MITIGATING MEASURES/

RELEVANT PROGRAMS, if any

BulSU-SP-QMS-02F1Revision: 0 Page 1 of 2

RISKS AND OPPORTUNITIES ASSESSMENT (ROA) - ORGANIZATION'S CONTEXT

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RATING

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DESCRIPTION OF OPPORTUNITY

OPPORTUNITY ASSESSMENT

ROA


RISKS AND OPPORTUNITIES ASSESSMENT (ROA) - NEEDS AND EXPECTATIONS OF INTERESTED PARTIES (NEIP)


OC

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CO

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RATING

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RIT

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CO

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RO

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RSRESIDUAL

RISK LEVEL

0 N/A 0 N/A

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0 N/A 0 N/A

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0 N/A 0 N/A

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NO INTERESTED PARTY DESCRIPTION OF RISK

RESIDUAL RISK



RISK ASSESSMENT

REQUIREMENTS (NEEDS and EXPECTATIONS)


RISKS AND OPPORTUNITIES ASSESSMENT (ROA) - NEEDS AND EXPECTATIONS OF INTERESTED PARTIES (NEIP)

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0 N/A FALSE

0 N/A FALSE

0 N/A FALSE

0 N/A FALSE

0 N/A FALSE

0 N/A FALSE

CONTINGENCY PLAN(for Moderate to High Risk after

RTAP)DESCRIPTION OF OPPORTUNITY


ROA


RISKS AND OPPORTUNITIES ASSESSMENT (ROA) - BUSINESS PROCESS


OC

CU

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CE

SE

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NO PROCESS DESCRIPTION OF RISKPROCESS REQUIREMENTS

RESIDUAL RISK



CONTINGENCY PLAN(for Moderate to High Risk

after RTAP)

RISK ASSESSMENT


RISKS AND OPPORTUNITIES ASSESSMENT (ROA) - BUSINESS PROCESS

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DESCRIPTION OF OPPORTUNITY


ROA



Document No.:



SETTING-UP, REVIEW AND RENEWAL OF QUALITY OBJECTIVES AND PROGRAMS

March 06, 2017 Revision No.:

0



QMR/ Director, IQAU





JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To provide BulSU an effective framework in setting up, reviewing and renewing its QMS objectives and programs, thereby ensuring the achievement of the commitments stated in BulSU quality policy.

2.0 SCOPE 2.1 This procedure describes setting up, review, and renewal of quality objectives and programs.

3.0 TERMS AND DEFINITIONS 3.1 Corrective Action – actions taken to prevent the occurrence and recurrence of a nonconformity.

3.2 Continual Improvement – recurring processes of enhancing the QMS to achieve improvements in

overall quality performance, in line with the quality policy.

3.3 Customer – person or organization who receives a product or service from BulSU; it may be internal or external to BulSU.

3.4 Customer Focus – any organization depends on their customers and therefore should understand current and future customer needs and should meet customer requirements and strive to exceed customer expectations.

3.5 Office Performance Commitment and Review (OPCR) – a document containing the QMS objectives and programs, the plan of activities, responsibilities, resources, and the time frame needed to achieve the objectives.

3.6 Quality Policy – statement of commitments, intentions and principles in relation to BulSU’s overall goals and directions with regard to its quality performance.

3.7 Objective – something sought for or aimed to achieve.

3.8 Program – set of activities needed to be done in order to achieve the objectives.

3.9 Quality Objectives – overall quality goals, arising from the quality policy, that BulSU sets itself to achieve, and which is quantified where practicable. Specific performance measures or milestones related to the achievement of the quality objectives.

3.10 Quality Performance – measurable results of the QMS, related to the control of BulSU on the quality of its operations, processes and services based on the quality policy.


Document No.:





0


4.0 REFERENCES

4.1 BulSU Strategic Plan

4.2 Office Performance Commitment Review (OPCR) from the Civil Service Commission

4.3 BulSU-SP-QMS-09, Management Review

4.4 BulSU-SP-QMS-10, Nonconformity and Corrective Action


Document No.:





0


5.0 DETAILS 5.1 Procedure Flow


Top Management/ QMS Working Team

1. Top Management/ QMS Working Team shall define overall goals and objectives for BulSU around which, each relevant College/ Office will define their objective

Top Management/ QMS Working Team

2. Quality issues may be identified through: − Business objectives − Strategic planning − Risks and opportunities − Gap analysis/ walk through audit − Review of past performance − Internal audit − External audit

Top Management/

QMS Working Team 3. Other factors to be considered are the

following: − Current compliance to applicable

legal and other requirements − Technological options available − Financial and University

requirements for the College/ Department/ Office; and

− Valid concerns/ views of interested parties, if any

QMS Working Team 4. Quality objectives and programs shall be included in the Office Performance Commitment and Review Form (OPCR). Details of the activities needed to achieve the goals, as well as the timelines for implementation/ achievement shall be clearly indicated.

START

Define goals and objectives

Consider significant quality issues

Document quality objectives and

program

A


Document No.:





0



QMS Working Team 5. A monitoring tool shall be created and used to track the implementation of actions and the achievement of the set objectives and programs. Tables, graphs, and charts may be in the reports.

Designated Functions/ QMS Working Team

Designated Function

6. Performance data shall be obtained from process monitoring and measurements and summarized into monthly and quarterly report. If applicable, Gantt charts shall be updated.

NO

YES QMR 7. Where necessary, objectives shall be revised in light of new developments, amendments or new legal requirements, and significant change in the scope of the management system. Additional programs may also be developed or implementation plan extended to achieve set objectives.

Head, College/ Department/ Office

8. Refer to procedure on Nonconformity and Corrective Action) for initiation of SIR.

A

Develop monitoring and measurement system

Implement actions and programs

Monitor implementation and

achievement

Achieved?

Initiate Corrective Action

END


Document No.:





0


5.2 The quality objectives and programs shall be in accordance to the strategic plans of BulSU.

5.3 Quality objectives shall be measurable, and if practical, quantifiable (current value, target value, time period) to facilitate a target/ actual value comparison.

5.4 Quality objectives and programs shall be set up within the first quarter of each calendar year where practicable. These shall be presented to Management Committee for review, allocation of resources, and final approval.

5.5 Progress in objectives and programs shall be monitored accordingly, and reported to Top Management. Summary reports shall be presented during Management Review which should be held at least once a year.

6.0 ATTACHMENTS None

7.0 FORMS None


Document No.:



CONTROL OF MONITORING AND MEASURING RESOURCES


0



QMR/ Director, IQAU





JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To establish general procedures in the identification, calibration and/ or verification and maintenance of monitoring and measuring equipment used in BulSU; and

1.2 To ensure reliability of monitoring and measurement results.

2.0 SCOPE 2.1 This procedure covers calibration and verification of monitoring and measurement equipment

used for quality parameters.

3.0 TERMS AND DEFINITIONS 3.1 Calibration – The process of determining the performance parameters of an instrument by

comparing it with measurement standards. Adjustment may be a part of a calibration, but not necessarily. A calibration assures that a device or system will produce results which meet or exceed some defined criteria with a specified degree of confidence.

3.2 Verification – The act of confirming the accuracy of certain equipment by comparing its performance with similar equipment that is appropriately calibrated.

4.0 REFERENCES

4.1 BulSU-SP-QMS-01, Control of Documented Information


Document No.:





0

This is a controlled documented information and must not be printed, photocopied without prior permission from the QMR.

5.0 DETAILS 5.1 Procedure Flow


Designated function in-charge of the equipment

1. All monitoring and measuring equipment shall be registered in the Master list of Monitoring and Measuring Equipment (BulSU-SP-QMS-04F1).


2. Determine calibration or verification schedule for the equipment taking into consideration the equipment manufacturer’s specifications, if available and/ or depending on the use and required accuracy of the equipment. Where necessary, obtain equipment specification from manufacturer’s manuals.

Designated

function in-charge of the equipment t

3. The Master List shall include but not limited to the following: − Unique identification and description of

the equipment and location; − Frequency of calibration/ verification; − Uncertainty/ tolerance requirements; − Date of previous and next calibration;

and − Action to be taken when results of

calibration/ verification is unsatisfactory


4. Equipment due for calibration or verification shall be withdrawn from use at least a month before its due date.

START

Identify/ Register equipment

Determine the calibration/ verification

schedule of the equipment

Monitor and identify equipment for

calibration/ verification

A


Document No.:





0




5. Equipment shall be sent to accredited external calibration laboratory for calibration. External calibration laboratory shall be preferably ISO 17025 accredited.

Designated

function in-charge of the equipment

6. Where practicable, one unit of similar equipment shall be sent for calibration and use the same in verifying the other unit(s).

Accredited Calibration Laboratory

7. The points/ graduation of equipment calibration shall be ensured to include the working range of the equipment.


8. The results of calibration shall be compared to the defined/ required tolerance (uncertainty) of the equipment.

YES

NO Head, College/ Department/

Office

9. Where necessary, the Head of relevant College/ Department/ Office using the equipment shall be consulted on the acceptability of the equipment. Equipment whose calibration result shows deviation from allowable tolerances shall be subjected to validity assessment and where necessary, shall be replaced immediately. Corresponding documentation shall be prepared.


10. Update Master List. Care shall be exercise on the equipment such that its calibration will not be damaged

Process Owner 11. Where applicable, use the calibrated

equipment to verify the accuracy and/ or workability of similar equipment.

A

Send equipment for calibration

Resume use/ Use equipment for

verification

B

Perform calibration

Evaluate results of calibration

Acceptable/ Accurate?

Replace


Document No.:





0



YES

NO Designated function in-charge of the equipment

12. Equipment whose verification result shows deviation from allowable tolerances shall be subjected to validity assessment and where necessary, shall be replaced immediately.


13. Update Master List and maintain records of calibration.

5.2 All monitoring and measuring equipment shall be kept clean and shall be protected from damage.

5.3 All repair works shall be done in accordance with the equipment manufacturer’s specification and

procedures and accepted engineering practices.


7.0 FORMS

7.1 BulSU-SP-QMS-04F1, Master List of Monitoring and Measuring Equipment

B

Tag equipment and resume use

END

Acceptable/ Accurate?

Replace

MASTER LIST OF MONITORING AND MEASURING EQUIPMENT (RESOURCES)

<College/ Department/ Office/ Unit>


NODESCRIPTION OF

EQUIPMENT/ RESOURCESEQUIPMENT ID LOCATION/ ASSIGNEE

CALIBRATION/ VERIFICATION FREQUENCY

OFFICE/ AGENCY CONDUCTING CALIBRATION/ VERIFICATION

TOLERANCE (UNCERTAINTY)

LAST CALIBRATION/ VERIFICATION

DATE

NEXT CALIBRATION/ VERIFICATION

DATE

ACTION TAKEN/ STATUS



Document No.:



INTERNAL AND EXTERNAL COMMUNICATION March 06, 2017

Revision No.:

0



QMR/ Director, IQAU





JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To describe the handling of internal and external communication to ensure that QMS-related matters and issues are effectively communicated to all levels and functions of the BulSU, and where necessary, are acted upon properly;

1.2 To establish procedures for effectively handling communication received from external interested parties which are relevant to the BulSU’s QMS; and

1.3 To describe the means by which the BulSU proactively communicates its quality performances and other initiatives to internal and external interested parties

2.0 SCOPE 2.1 This describes internal communication arrangements within BulSU; from management to others

and others to management; and

2.2 This procedure covers all forms of QMS-related communication received by the BulSU from relevant external interested parties such as regulatory bodies, customers, subcontractors and other relevant external interested parties.

3.0 TERMS AND DEFINITIONS 3.1 External Communication – communication received from other parties such as customers,

business partners and regulatory bodies

3.2 Internal Communication – communication within BulSU management and employees

4.0 REFERENCES





Document No.:




Revision No.:

0


5.0 DETAILS 5.1 Handling Internal Communication


Any employee 1. Any employee can communicate with another employee his/ her concerns on issues that relate to the quality performance of the BulSU and its management systems following the communication flow in Section 5.4 of this procedure.

Any function defined in the

communication flow

2. Communication may be received through any of the following: Memo Bulletin Announcements Meetings E-mails Newsletters Etc

Function receiving the communication

3. This process shall cover only relevant communication concerning the management system and the quality performance of BulSU.

The function receiving the communication

must copy furnish the QMR.

Relevant Function

4. Valid internal concern/ issue/ suggestion for improvement to quality performance of the BulSU and its management systems, including actions taken shall be recorded in Logbook for Internal/ External Communication (BulSU-SP-QMS-05F1)

START

Raise concern/ issue/ suggestion

Receive communication

Forward to relevant function

Keep a file of the concern/ issue/

suggestion

A


Document No.:




Revision No.:

0



Relevant Function 5. Concerns may be brought up/ discussed during meetings or in any avenues discussed above

QMS Working

Team 6. Where necessary, QMS Working Team

may assign a function to validate or investigate further a highly significant/ important communication

YES

NO

Relevant Function 7. Where practicable, the Relevant Function shall reply/ relay findings following the communication flow within the BulSU.

Relevant Function 8. Concern/ Issue/ Suggestion for improvement confirmed valid shall be documented using SIR

QMR 9. Function responsible for taking appropriate action and communication of the results of investigation including status shall be assigned by the QMR

QMR/ DC 10. Update record of internal communication, Logbook for Internal/ External Communication (BulSU-SP-QMS-05F1)

QMR 11. Information on valid internal

communication including actions taken shall be consolidated and presented during the periodic management review

A

Validate/ Investigate concern/ issue

Valid?

Initiate Corrective Action

Integrate to QMS and communicate results

Retain documented information

END

REPLY


Document No.:




Revision No.:

0


5.2 Handling External Communication


Anybody 1. Any BulSU employee may receive communication from external interested parties. Received communication may be written [letter, fax message], verbal [by phone, walk-in, personally approached by the source], through text messages, e-mails, or through the mass media [TV, radio, broadsheets]

Anybody receiving the communication

2. Where practicable, identify addressee and nature of communication (sealed letters may not be opened) before forwarding communication to Document Controller.

Document Controller

3. Record QMS-related communications in Logbook for Internal/ External Communication (BulSU-SP-QMS-05F1).

College/

Department/ Office Head

4. A copy of all written communication addressed to the College/ Department/ Office Head shall be forwarded to the Document Controller for appropriate recording. Phone calls on the other hand, shall be endorsed to the function concerned, where practicable. Otherwise, the communication shall be received by whoever answers the phone and forward details to Document Controller later.

Document Controller

5. Communication received from external interested parties concerning BulSU’s operations and quality performances may be: − Request for information. Requests

for information shall be directed to the QMR and/ or Head of the College/ Office and/ or President

.

START

Receive external communication

Forward communication to Document Controller

Record and classify communication

Forward communication to relevant function

A

A


Document No.:




Revision No.:

0



Note: The QMR may decide on

communication received in consultation with relevant functions

Document

Controller − QMS-related concerns/ complaints

including Notice of Violation or other communication from regulatory bodies. Quality-related concerns/ complaints shall be forwarded to the President or QMR.

Note: Sensitive information that may

negatively affect the image of BulSU, including communication from and with the media, shall be forwarded to the QMR and/ or President for clearance and for possible further action.

Relevant Function

YES

NO QMR 6. Acknowledgement/ response to communication shall be done within five (5) working days upon receipt of communication.

QMR 7. Actions to valid external communication may be by granting the request or through correspondence with the Sender. Legal violations and valid complaints shall be addressed with SIR form in accordance with procedure on nonconformity and corrective action.

QMR 8. Where necessary, the implementation of

required actions shall be coordinated with relevant functions within BulSU.

Validate and classify nature of

communication

Valid?

Implement necessary action

B

B

REPLY


Document No.:




Revision No.:

0



QMR 9. All written communication to external interested parties that relate to BulSU’s quality performances shall be noted by the QMR, copy of which shall be forwarded to Document Controller for recording.

Document

Controller 10. The Logbook for Internal/ External

Communication shall be updated

Reply and record action taken

END


Document No.:




Revision No.:

0


5.3 Proactive Communication (Bulletins, Announcements and Advisories)


Document Controller

1. Relevant quality-related performance indicators shall be determined in consultation with College/ Department/ Office Heads and/ or the QMS Working Team

QMR 2. The amount or nature of information about the BulSU performances that may be communicated externally shall be decided in consultation with the QMR, where necessary

QMR 3. Information that could negatively affect

the image of the BulSU shall be cleared with the QMR and/ or President, i.e., Notice of Violation, emergencies, incidents, etc.

Document Controller

4. Information for posting in the Bulletin shall be stamped “Approved for Posting” by the Document Controller.

Document Controller

5. In addition to other information approved for posting, the following information shall be displayed in the bulleting, at minimum: − Quality Policy − Where available, progress against set

quality objectives

Document Controller

6. The information in the Bulletin shall be updated weekly and where practicable.

5.4 Communication with customers, consultants, contractors, and suppliers

START

Determine what to communicate/ post in the

Bulletin

Review and approve information for

communication/ posting

Stamp and record information

Post in the Bulletin/ Communicate

information

Regularly update information

END


Document No.:




Revision No.:

0


5.4.1 The Procurement Unit of BulSU shall be responsible for communicating requirements

and other arrangements with suppliers and contractors prior to purchase.

5.5 The QMR shall be responsible in consolidating records of and in monitoring QMS-related internal and external communications.

5.6 BulSU personnel shall be represented in the development and review of QMS-related policies and procedures, including in the setting-up and renewal of objectives and programs related to the BulSU’s quality performance and its management systems.

5.7 Information to be periodically communicated and made available for possible consultation shall be documented in the BulSU-SP-QMS-05F2, QMS Communication Plan include among others the following:

5.7.1 BulSU’s Quality policy, objectives and programs;

5.7.2 Relevant management system procedures, standard operational procedures and best

practices and the consequences of not following them;

5.7.3 Performance of the BulSU’s management system including relevant highlights/ results of management system audits and periodic reviews;

5.7.4 New policies, directives and other changes that may affect the quality performance of BulSU and its management systems; and

5.7.5 Any valid complaint and concern that relate to the BulSU’s quality performance

5.8 The above information may be communicated during visit of external interested parties to BulSU’s general orientation among visitors, suppliers and contractors, and during its participation to relevant conferences and conventions.

5.9 To effectively document meetings related to the management system, the following shall be observed: 5.9.1 Agenda, attendees, date, time, and venue shall be defined. These shall be

communicated to the attendees ahead of time, using memos/ office orders

5.9.2 Attendance during the meeting shall be recorded using Attendance Sheet (BulSU-SP-QMS-05F3). Member of the QMS Working Team shall be designated to take the minutes.

5.9.3 Any decision and/ or action items arrived at during the meeting shall be documented using Minutes of the Meeting (BulSU-SP-QMS-05F4). Once approved, the highlights of the Minutes of Meeting shall be communicated to relevant functions and interested parties.

5.10 The general flow of internal communication within BULSU shall be as follows:


Document No.:




Revision No.:

0


5.11 Valid communication (internal and external), and action taken shall be integrated in the management system operational procedure and/ or best practices, where practicable.

5.12 Where practicable, relevant interested parties such as employees, customers, contractors and suppliers, neighbours and other interested parties shall be consulted on matters that may impact BulSU’s quality performance.

5.13 Confirmed legal violation and valid concern/ issue from external interested parties shall be documented and addressed with a SIR form, in accordance with the established procedure on corrective action.

5.14 Information that could negatively affect the reputation of BulSU shall be cleared with the Top Management prior to communication, i.e. Notice of Violation, accidents, emergencies, etc.


7.0 FORMS 7.1 BulSU-SP-QMS-05F1, Logbook for Internal/ External Communication

7.2 BulSU-SP-QMS-05F2, QMS Communication Plan

7.3 BulSU-SP-QMS-05F3, Attendance Sheet

7.4 BulSU-SP-QMS-05F4, Minutes of Meeting

Employees and Staff

QMR and Communications Group

President

Deans/ Department Heads

Vice Presidents

LOGBOOK FOR INTERNAL/ EXTERNAL COMMUNICATION


DATE RECEIVED

RECEIVED BY

SOURCE/ CONTACT ADDRESS

DESCRIPTION/ NATURE OF COMMUNICATION

DATE & ACTION TAKEN REMARKS/

STATUS

COMMUNICATION PLAN


As of:

WHAT INFORMATION TO COMMUNICATE

WHEN TO COMMUNICATE

MECHANICS OF COMMUNICATIONINTERNAL INTERESTED PARTIES EXTERNAL INTERESTED PARTIES

With Whom How Responsibility With Whom How Responsibility 1.

2.

3.

4.

5.

Prepared by: Reviewed by: Approved by:

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name

ATTENDANCE SHEET


SUBJECT:

VENUE:

DATE: TIME:

NO. FULL NAME

(Last Name, First Name, M.I.) DESIGNATION

COLLEGE/ DEPARTMENT/

OFFICE SIGNATURE

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

MINUTES OF MEETING


Subject:

Venue: Date Conducted: A. Present during the meeting

Name Office Position

B. Absent during the meeting (where appropriate, indicate reason for absence)


C. Other attendees during the meeting


D. Chaired by: Time Started: E. Highlights of the Meeting

AGENDA / HIGHLIGHTS WHO/ WHEN

1.

2.

3.

4.

5.

F. Time Adjourned: G. Tentative Date of Next Meeting:

Prepared by:

Approved/ Noted by:

Signature Over Printed Name Signature Over Printed Name


Document No.:



CONTROL OF NONCONFORMING OUTPUTS March 06, 2017

Revision No.:

0



QMR/ Director, IQAU





JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To describe the means of identifying product nonconformities and determining subsequent actions taken, preventing its unintentional release to the next process or customer.

2.0 SCOPE 2.1 This procedure covers the following nonconformities:

2.1.1 Incoming materials/ supplies that could affect the quality of the services of BulSU found

not meeting purchase specifications;

2.1.2 In-process services that failed to meet the required specification (defined in the quality control plans) at a certain stage of business processes; and

2.1.3 Products and services that failed to meet customer, organization and regulatory requirements.

3.0 TERMS AND DEFINITIONS 3.1 Correction – action taken to correct or stop or mitigate the impacts of a detected nonconformity

or other undesirable and substandard condition.

3.2 Corrective Action – action to eliminate the cause of a nonconformity and to prevent recurrence or occurrence.

3.3 Nonconforming output – supplies and materials, including equipment and parts found not meeting specified requirement or services performed by BulSU personnel or provided by service contractors found not meeting specified requirements


Document No.:




Revision No.:

0


4.0 REFERENCES




Document No.:




Revision No.:

0


5.0 DETAILS


Process Owner 1. Nonconforming output may be detected during periodic monitoring and measurement activities. Refer to Attachment (List of Nonconforming Products and Services, Controls and Disposition) for a listing of possible nonconforming products and services.

Process Owner 2. Nonconforming output shall be segregated and properly labelled. Where practicable, nonconforming outputs shall be tagged and isolated. Details of nonconformity shall be recorded in the prescribed form, Logbook of Nonconforming Outputs (BulSU-SP-QMS-06F1)

Process Owner 3. Where practicable, nonconforming product

shall be re-confirmed by the immediate superior of the function detecting the nonconformity.

Designated Function in Relevant

Department/ College/ Office

4. Necessary corrections and controls shall be applied as prescribed in the QCP and/ or as stated in the Attachment.



5. Nonconforming outputs subjected to correction or rework shall be re-verified before use or release to the next process

A

Take action to address the nonconforming

output

Identify nonconforming output

Detect nonconforming output

START


Document No.:




Revision No.:

0





6. See BulSU-SP-QMS-06F2, List of Nonconforming Outputs, Controls and Disposition.



7. Supporting documented information shall be retained following the procedure on Control of Documented Information.

6.0 ATTACHMENTS

None

7.0 FORMS 7.1 BulSU-SP-QMS-06F1, Logbook for Nonconforming Outputs

7.2 BulSU-SP-QMS-06F2, List of Nonconforming Outputs, Controls and Disposition

END

Retain documented information

Implement disposition

A

LOGBOOK OF NONCONFORMING OUTPUTS


AREA/ PROCESS:

NO DATE

(mm/dd/yy) NATURE OF NONCONFORMITY DETECTED BY

DISPOSITION/ ACTION TAKEN & DATE

VERIFYING FUNCTION

STATUS/ REMARKS

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

LIST OF NONCONFORMING OUTPUTS, CONTROLS AND DISPOSITION


ITEM NO

TYPE OF NONCONFORMING OUTPUTS

INSPECTION/ MONITORING

FUNCTION

IDENTIFICATION AND CONTROL

RECORDS GENERATED

VERIFYING FUNCTION

DISPOSITION/ CORRECTION

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.


Document No.:



MONITORING CUSTOMER SATISFACTION March 06, 2017

Revision No.:

0



QMR/ Director, IQAU





JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To establish a system for monitoring customer’s perception as to whether or not any BulSU is satisfying their requirements during the provision of its instruction, research and extension services; and

1.2 To have a system of determining and understanding customer requirements and use this as basis in identifying areas for continual improvement, with the aim of enhancing customer satisfaction.

2.0 SCOPE 2.1 This covers BulSU’s means of monitoring perception of the identified customer(s).

3.0 TERMS AND DEFINITIONS 3.1 CSS – Customer Satisfaction Survey

4.0 REFERENCES


5.0 DETAILS


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5.1 Customer Satisfaction Survey


QMS Working Team

1. The request to accomplish the CSS questionnaire shall be communicated to the customers.

Customer 2. The CSS questionnaire maybe accomplished by more than one person.

QMS Working Team

3. Where necessary, follow up shall be conducted one week after sending out the survey questionnaire. Survey questionnaire that is not returned before the next evaluation cycle shall be treated as non-participation and may no longer be followed-up.

4. Accomplished survey questionnaire

received beyond the deadline [evaluation cycle] shall still be processed in accordance with the applicable provisions of this procedure.

QMS Working Team

5. Accomplished questionnaires shall be processed/ analyzed as these are received. Applicable statistical tools maybe used.

QMS Working Team

6. Refer to Section 5.5 of this procedure for necessary actions to be taken. Valid concerns and complaints shall be acted upon and where necessary, validated or investigated timely, in accordance with the established procedure on nonconformity and corrective action

START

Send CSS request

Accomplish CSS

Follow-up accomplished CSS questionnaire

Process/ Analyze accomplished CSS

questionnaire

Determine appropriate action

A


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QMS Working Team

7. Results of the CSS and actions taken (if any) shall be communicated to Customer where necessary.

QMS Working Team

8. Where applicable, actions taken or best practices resulting from the CSS shall be integrated in the management system including possible revision of the BulSU policies and procedures

QMS Working Team

9. Results of customer perception monitoring including actions taken shall be presented in the management review.

5.2 Coordination meeting – Each College/ Department/ Office calls for or attends to meetings with other College/ Department/ Office.

5.2.1 The attendees to this meeting exchange information such as requirements, planned

activities, schedules, standard operational problems and issues, feedback, including complaints.

5.2.2 Designated persons record these issues and ask for the minutes of the Coordination Meeting.

5.2.3 Designated persons relay the information to concerned units or function for appropriate action.

5.3 Customer Satisfaction Survey

5.3.1 Function responsible shall request from different College/ Department/ Office feedback and complaints regarding the provision of their products or services

5.4 Handling of Complaints – customer complaints may indicate negative customer satisfaction. However, proper handling of complaints may eventually result in customer satisfaction, or identify improvement opportunities. Each College/ Department/ Office shall define a means by which customers can file their complaints. Student complaints or grievance shall be handled by the Student Affairs.

A

Communicate results

Integrate changes in the QMS

Monitor status of action

END


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5.5 Survey Results and Recommended Action

RESULT ACTION

A. Rating is below expectation (Poor or Very Poor): – Average rating of Respondent is < “2” – Average total customer satisfaction

rating is < “2”

Initiate corrective action using in accordance with BulSU-SP-QMS-10, Nonconformity and Corrective Action

B. Respondent gave a reasonable statement of complaint or concern

Initiate corrective action using in accordance with Nonconformity and Corrective Action

C. Conflicting Data – High rating (rating higher than “3”) in

relevant criteria but has complaint and/ or statement of praise/ commendation but with low rating (rating below “2”) in relevant criteria

Clarify with Customer where practicable. Otherwise, exclude the whole survey form

D. Comparative analysis shows decreasing trend for 3 consecutive evaluation cycle: – Comparative analysis of rating for each

criterion (current vs. previous ratings) – Comparative analysis of the average

rating per customer classification – Total average customer satisfaction

rating for the cycle – Performance against set objective, if

any

Initiate corrective action using in accordance with Nonconformity and Corrective Action

6.0 ATTACHMENTS

None

7.0 FORMS 7.1 BulSU-SP-QMS-07F1, Customer Satisfaction Survey

CUSTOMER SATISFACTION SURVEY (CSS)


In line with our commitment to understand your requirements and seek to satisfy your needs consistently, we would like to know the level of your satisfaction on the services we have provided. Your response will be a vital input in the review and continual improvement of our services and of our Quality Management Systems. We sincerely appreciate your cooperation. Thank You!

Name of Respondent (optional):

Position (optional): Tel: Date:

Please indicate your satisfaction by placing a check (√ ) on the listed criteria below using the following rating scheme:

1 – Below Standards (Poor), 2 – Meets Standards (Good), 3 – Exceeds Standards (Very Good), 4 – Outstanding

PERFORMANCE CRITERIA SATISFACTION LEVEL

1 2 3 41. Quality of Service (40%)

a. Service/ assistance provided complete? b. Services reliable? (i.e. availability of services, accuracy of results, etc.)

2. Technical Competency (30%)

a. BulSU employees and staff demonstrated mastery, expertise, and overall competence on services provided?

b. Technical questions and concerns answered satisfactorily?

3. Customer Relations (15%) a. BulSU employees and staff courteous and helpful? b. BulSU employees and staff listen and communicate well?

4. Timeliness of Service (15%)

a. Requests, complaints and feedback are handled and responded to promptly?

b. Services delivered timely?

Please indicate below your other concerns or suggestions on how we can further improve our services.

Kindly return the accomplished form to any representative of the QA department. Once again, thank you for taking time to answer this survey! FOR QA USE ONLY:

TOTAL SCORE:


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INTERNAL QMS AUDIT March 06, 2017

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QMR/ Director, IQAU





JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To establish a system for planning, conducting and assessing internal audits of quality management system (QMS); and

1.2 To establish a system for reporting and follow up of internal audit results to the Management, thereby ensuring that the QMS is effectively implemented and maintained.

2.0 SCOPE

2.1 This procedure applies to all colleges/ departments/ offices, processes and functions covered by

the BulSU’s QMS

3.0 TERMS AND DEFINITIONS 3.1 Audit – systematic, independent, documented process for obtaining audit evidence and evaluating

it objectively to determine the extent to which audit criteria are fulfilled.

3.2 Audit conclusion – outcome of an audit provided by the auditor or team of auditors, after consideration of the audit objectives and all audit findings.

3.3 Audit criteria – set of policies, procedures or requirements used as reference in the audit.

3.4 Audit findings – results of the evaluation of the collected evidence against audit criteria. Audit findings can be classified as follows:

3.4.1 Positive Findings – conformities to the management system which are commendable;

best practices that can be benchmarked by others. It could be in a form of award, achievement/ performance, attitude, etc.

3.4.2 Nonconformity – failure to fulfill a specified requirement of the international standards, applicable permit/ license, legal limits for regulated pollutants/ threshold limit value (TLV) and the requirements of the management system. Depending on the degree or magnitude of deviation, a nonconformity shall be classified into: 3.4.2.1 Major – (System Breakdown) total failure to fulfill a specified requirement of

the standard that is applicable to the organization

a. Absence of documentation or non-implementation of the entire procedure required by the International Standards;

b. Where the nonconformity represents a repeating or widespread failure to implement the requirement of the QMS based on ISO 9001 Standard;


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c. Failure to achieve QMS performance measures that can lead to an

unacceptable risk and where BulSU has failed to take corresponding effective corrective action;

d. When a nonconformity is directly related to failure to recognize and record when an objective is not met or defined programs are not implemented as planned; and

e. Aggregation of minor non-conformities

3.4.2.2 Minor – lapse in the system that has limited effect on the integrity of the management system or quality performance of BulSU such as the following:

a. Inconsistency in the implementation of a procedure

b. Non-implementation of some requirements of a procedure

c. Missing some documents, records, signature, incomplete data, etc.

3.4.3 Observation – An observation is not nonconformity but something that could lead to a

nonconformity, if allowed to continue uncorrected. It could also be an isolated lapse in the documentation or implementation of the management system which did not result to legal noncompliance and/ or injury or illness. Not directly limited to the requirements of the standards; and

3.4.4 Hints for Improvement – Conforming to the basic requirements of the management system standard or legal requirements, but can be further improved; findings which have no direct evidence of failure but are suspect in terms of long-term sustainability of the management system. NOTE: Refer to BulSU-SP-QMS-10, Nonconformity and Corrective Action procedure for detailed descriptions of nonconformities and when to issue SIR.

3.5 Audit plan – set of one or more audits planned for specific time frame and directed towards a

specific purpose. This is also referred to as Audit Program

3.6 Auditee – function being audited

3.7 Auditor – person with the competence to conduct an audit.

3.8 Correction – action taken to correct or stop or mitigate the impacts of a detected nonconformity or other undesirable and substandard condition.


3.10 Follow-up Audit – verification of corrective actions to be implemented which is normally done after

the agreed implementation timetable.

3.11 Internal QMS Audit – a check on an organization’s own integrated management system which may be performed by its own personnel or by external parties on their behalf


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4.0 REFERENCES





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5.0 DETAILS


Lead Internal Auditor 1. The program may be prepared and finalized during the last quarter of the year but not later than the third week of January of the following year. The Annual Internal Audit Program (BulSU-SP-QMS-08F1) shall be accomplished.

Lead Internal Auditor 2. The entire QMS shall be audited at least

once a year, taking into consideration the status and importance of the processes/ areas/ functions to be audited and results of previous audits. Note: The cycle for internal auditing should normally be completed in one year, such that interval should not be more than 12 months.

Lead Internal Auditor 3. A periodic review of previous audit results

(both internal and external) shall be done to assess the need for another audit for a certain area or to validate cancellation of audit scheduled for a specified area.

Designated Function/

Lead Internal Auditor

4. An Internal QMS Audit Matrix (BulSU-SP-QMS-08F2) shall be developed and regularly updated to determine applicable clauses for each audit process/ area/ function. Guide questions may be developed to help determine whether the audit process/ area/ function shall be audited primarily on the particular clause or if only awareness/ status of implementation shall be audited.

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B

Prepare/ Update Internal Audit Program

Prepare/ Update Audit Matrix

A


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QMR 5. To gain commitment and support, it shall be useful for the Annual Internal Audit Program and the Audit Matrix to be signed by the QMR.

YES

NO



6. Members of the Audit Team shall be selected from the pool of qualified internal auditors.

QMR 7. At the minimum, the auditors must have

completed the following trainings or their equivalents: Appreciation Course on the

management system standard(s) i.e. ISO 9001:2015

Internal QMS Audit Course Designated

Function/ Lead Internal Auditor/ QMR

8. Selection and assignment of auditors shall take into considerations their skills, familiarity with the BulSU’s processes, and knowledge of relevant legal requirements. Cross audit may be allowed within the College/ Office (at minimum) provided that the auditor is not from the same college/ department/ officer unit to ensure impartiality and objectivity of the audit.



9. The Internal Audit Itinerary (BulSU-SP-QMS-08F3) shall be prepared for the whole system or per defined scope. The scope and purpose of the audit including time allocation for the conduct of the audit, team meetings and preparation of audit reports shall be indicated in the Audit Itinerary.

A

Review/ Approve Audit Program and Audit Matrix

Organize/ Identify members of Internal Audit

Team

Prepare the Internal Audit Itinerary

C

Approved?

B


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QMR 10. The Internal Audit Itinerary shall be

reviewed and/ or approved by the QMR

Lead Internal Auditor 11. The Audit Plan shall be communicated to the College/ Department/ Office through email or hard copy at least a week before the scheduled audit.


Lead Internal Auditor/

Audit Team Members

12. Use Internal QMS Audit Checklist (BulSU-SP-QMS-08F4). The Checklist shall include guide questions, key requirements of relevant policies, procedures and work instructions, and records using the Audit Matrix as reference.

Audit Team

Members 13. Where applicable, verification of the

implementation and/ or effectiveness of actions taken to previous audit findings shall be prompted in the checklist.

Lead Internal Auditor/ Audit Team

Members

14. The Lead Internal Auditor may conduct a general Opening Meeting to reconfirm scope, purpose and schedule of audit and to solicit everybody’s cooperation during the audit. The individual Team may conduct informal Opening Meeting in the area to reconfirm the same and to set the mood of audit.

Audit Team

Members 15. The audit shall be conducted following as

closely as possible the Internal Audit Plan. Audit evidences shall be obtained by examining documents and records, interviewing personnel and observing the physical condition of site and/ or practices. Audit evidences obtained shall be recorded in the checklists.

Audit Team

Members 16. Initial feedback on the general results of the

audit shall be provided to the management of the audited function/ unit.

D

Communicate Audit Itinerary

Prepare/ Review/ Revise checklists

Conduct the Audit

E


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Lead Internal Auditor/ Audit Team

Members

17. Members of the Audit Team shall meet as a team to consolidate, discuss and agree on the classification of audit findings and encode in the Monitoring of Audit Findings Form (BulSU-SP-QMS-08F5); refer to this procedure for the classification of audit findings.

YES

NO Audit Team Members

18. Refer to procedure on Nonconformity and Corrective Action, (BulSU-SP-QMS-10), for audit findings needing issuance of SIR.

Audit Team Members/ Lead Internal Auditor

19. SIR (BulSU-SP-QMS-10F1) shall be used.

Audit Team

Members 20. Internal QMS Audit Report (BulSU-SP-

QMS-08F5), shall be prepared and duly signed by Audit Team per audit area/ function/ colleges/ departments/ offices

Audit Team Members

21. The Audit Team may conduct individual Closing Meeting with the Management of the audited area/ function/ colleges/ departments/ offices to present the results of the audit and where available, to obtain acknowledgement of the Audit Report including SIR, if any, by the audited function and the Dean of the Colleges/ Head of Departments/ Offices

Lead Internal Auditor 22. A general Closing Meeting may also be

conducted by the Lead Internal Auditor after all the Audit Teams have completed their audit to present the overall results of the audit and obtain commitments from the College/ Department/ Office Heads for appropriate actions on the audit results.

E

Conduct auditor’s meeting

Prepare SIR

F

Conduct Closing Meeting

G

Need CA? F


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Audit Team

Members 23. Copies of the Internal Audit Report and SIR

(if any) shall be provided to the Lead Internal Auditor within five (5) working days after the conduct of the audit.

Lead Internal

Auditor/ Designated Function

24. Issuance of audit report including SIR shall be within seven (7) working days after the conduct of the audit.

Lead Internal Auditor / Designated

Function

25. Issued SIR shall be processed and followed-up in accordance with the procedure on nonconformity and corrective action.

Lead Internal

Auditor/ Designated Function

26. Audit Observations and Hints for Improvements which are not appropriately acted upon may be escalated to the next level of audit findings and/ or to the next Management level.

Head, Colleges/

Offices 27. Updates on audit findings and actions taken

to address them may be presented and discussed during operational meetings of the College/ Department/ Office.

Lead Internal Auditor/

Designated Function 28. The approved audit program, audit matrix,

audit itineraries, accomplished checklists and prepared reports shall be maintained following the procedure on Control of Records.

Lead Internal Auditor/ QMR

29. The overall conclusion of the audits, recommendations for succeeding audits (including additional training and other resource needs, if any) and status of corrective and preventive actions taken shall be presented and discussed during management reviews.

G

Monitor audit results

Present audit conclusion and

recommendations

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6.0 ATTACHMENTS

None

7.0 FORMS 7.1 BulSU-SP-QMS-08F1, Annual Internal Audit Program

7.2 BulSU-SP-QMS-08F2, Internal QMS Audit Matrix

7.3 BulSU-SP-QMS-08F3, Internal QMS Audit Itinerary

7.4 BulSU-SP-QMS-08F4, Internal QMS Audit Checklist

7.5 BulSU-SP-QMS-08F5, Monitoring of Audit Findings

ANNUAL INTERNAL QMS AUDIT PROGRAM

CY: YYYY (As of ________________)

FUNCTION/ PROCESS/ AREA P/ A MONTHS

AUDITOR REMARKS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

P A

P A

P A

P A

P A

P A

P A

P A

P – PLAN A - ACTUAL



Reviewed by: Reviewed by: Approved by:


INTERNAL QMS AUDIT MATRIX


CLAUSE/ ITEM

REQUIREMENTS

AREA/ PROCESS/ FUNCTION

REMARKS

ISO 9001:2015 4 CONTEXT OF THE ORGANIZATION

4.1 Understanding the organization and its context 4.2 Understanding the needs and expectations of interested parties 4.3 Determining the scope of the QMS 4.4 QMS and its processes 5 LEADERSHIP

5.1 Leadership and commitment 5.1.1 General 5.1.2 Customer Focus 5.2 Policy

5.2.1 Establishing the quality policy 5.2.2 Communicating the quality policy 5.3 Organizational roles, responsibilities and authorities 6 PLANNING

6.1 Actions to address risk and opportunities 6.2 Quality objectives and planning to achieve them 6.3 Planning of changes 7 SUPPORT

7.1 Resources 7.1.1 General 7.1.2 People 7.1.3 Infrastructure 7.1.4 Environment for the operation of processes 7.1.5 Monitoring and measuring resources

7.1.5.1 General 7.1.5.2 Measurement traceability 7.1.6 Organizational knowledge 7.2 Competence 7.3 Awareness 7.4 Communication



CLAUSE/ ITEM

REQUIREMENTS


REMARKS

7.5 Documented information 7.5.1 General 7.5.2 Creating and updating 7.5.3 Control of documented information

8 OPERATION 8.1 Operational planning and control 8.2 Requirements for products and service

8.2.1 Customer communication 8.2.2 Determining the requirements for products and services 8.2.3 Review of the requirements for products and services 8.2.4 Changes to requirements for products and services

8.3 Design and development of products and services 8.3.1 General 8.3.2 D&D planning 8.3.3 D&D inputs 8.3.4 D&D control 8.3.5 D&D control 8.3.6 D&D changes 8.4 Control of externally provided process, products and services

8.4.1 General 8.4.2 Type and extent of control 8.4.3 Information for external providers 8.5 Production and service provision

8.5.1 Control of production and service provision 8.5.2 Identification and traceability 8.5.3 Property belonging to customers or external providers 8.5.4 Preservation 8.5.5 Post-delivery activities 8.5.6 Control of changes 8.6 Release of products and services 8.7 Control of nonconforming outputs 9 PERFORMANCE EVALUATION

9.1 Monitoring, measurement, analysis and evaluation



CLAUSE/ ITEM

REQUIREMENTS


REMARKS

9.1.1 General 9.1.2 Customer satisfaction 9.1.3 Analysis and evaluation 9.2 Internal audit 9.3 Management Review 10 IMPROVEMENT

10.1 General 10.2 Nonconformity and corrective action 10.3 Continual improvement

LEGENDS: X Key function to be audited; compliance to a procedure O Awareness, understanding, and practices to be audited



Reviewed by: Reviewed by: Approved by: Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name

INTERNAL QMS AUDIT ITINERARY


AUDIT DATES:

AUDIT TEAMS:

A

B

OBJECTIVES:

SCOPE:

REFERENCE STANDARDS & CRITERIA:

DATE/ TIME AREA/ PROCESS/

FUNCTION AUDIT FOCUS AUDITEE AUDITOR

Prepared by: Approved by:

Signature Over Printed Name/ Date Signature Over Printed Name/ Date

Lead Internal QMS Audit QMR

INTERNAL QMS AUDIT CHECKLIST


AREA /PROCESS/ FUNCTION AUDITOR (S) AUDITEE(S) DATE

CLAUSE/ ITEM

REQUIREMENTS EVIDENCES RESULTS

(Y/ NC/ O/ H/ N/A)

Legends: Y – Conformity NC– Nonconformity O – Observation H – Hint for Improvement N/A – Not applicable during the audit

MONITORING OF AUDIT FINDINGS


DATE:

ITEM NO

FINDING STATEMENT (Auditor)

[PO/ NC/ OB/HI]

CLAUSE


AUDITORSRESPONSIBLE

FUNCTION ACTION TAKEN

(Auditee)

COMPLETIONDATE

(Auditee)

STATUS[C/OG/ E](Auditor)

REMARKS (Auditor)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

SUMMARY OF AUDIT FINDINGS: A B TOTALPositive Nonconformity Observation Hints for Improvement TOTAL

LEGENDS: PO – Positive Points NC – Nonconformity OB – Observation HI– Hints for Improvement C – Completed OG – Action on-going E – Escalate to next level of audit finding/ next level of management

Prepared by: Approved by:

Signature Over Printed Name/ Date Signature Over Printed Name/ Date

Lead Internal QMS Audit QMR


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MANAGEMENT REVIEW March 06, 2017

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QMR/ Director, IQAU





JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To ensure the BulSU’s management system is formally and periodically evaluated to assess its continuing suitability, adequacy and effectiveness, and to identify opportunities for continual improvement.

2.0 SCOPE

2.1 This procedure covers the conduct of the 2nd- tier review of the management system of BulSU

3.0 TERMS AND DEFINITIONS 3.1 Continual improvement – recurring processes of enhancing the management system to achieve

improvements in overall quality performance of the college/ department/ office, in line with the BulSU Quality Policy.

3.2 Management review – top management assessment of the continuing suitability, adequacy and effectiveness of the management system. The review includes assessing opportunities for improvement and the need for changes to the management system, including the Quality Policy and objectives. A two-tier management review shall be conducted as follows: 3.2.1 1st tier – shall be in the College/ Department/ Office level, which shall focus on day-to-

day issues and implementation of the management system. This review shall be chaired by the Deputy QMRs/ College/ Department/ Office Heads. The Review Team at this level shall include at minimum, all the Heads of the College/ Department/ Offices/ Units, College/ Department/ Office Representative in the QMS Working Team and Document and Record Custodian.

3.2.2 2nd tier – shall be a dedicated review of the management system which shall be

conducted at least once a year. This periodic review shall be conducted by the defined Management Review Committee (Refer to the functional structure of the management system) and chaired by the Top Management/ President. The Committee comprises at minimum the President, Management Committee, QMR, Deputy QMRs, Document Controller and the Lead Auditor of the Internal QMS Audit.

4.0 REFERENCES


4.2 BuLSU-SP-QMS-08, Internal QMS Audit

4.3 BuLSU-SP-QMS-10, Nonconformity and Corrective Action


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5.0 DETAILS


Designated Member of the Top

Management

1. The 2nd tier Management Review shall be conducted at least once a year. The Designated Member of the Top Management shall call an emergency meeting if a major management system problem is detected or has occurred.

Designated

Member of the Top Management

2. Refer to Attachment A – Management Review Agenda. All applicable agenda for the period covered shall be taken up during the review

Designated


3. Defined review agenda discussed during the 1st tier management review shall be consolidated/ summarized for presentation during the 2nd tier Management Review.

Designated


4. Where need arises, the Designated Member of the Top Management shall identify attendees in addition to the regular membership of the Review Committee.


Management

5. Where necessary, the Designated Member of the Top Management shall request members of the Management Review Team to collect and prepare information/ data in relation to the defined agenda.

Designated Functions

6. Information/ Data shall be consolidated and where appropriate, analyzed by the designated functions.

Designated


7. The date and venue shall be decided preferably in consultation with the other members of the Review Team.

A

Decide on the date and venue

Prepare information/ data

Assign Responsibilities

Organize/ Confirm Attendance

Define Review Agenda

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Management

8. The Designated Member of the Top Management shall chair the review and shall assign a member of the Review Team to take and prepare the minutes.

9. The outputs of the review shall be included

among others the following: Improvement of the effectiveness of the

management system Improvement of products/ services

related to customer requirements Resource needs Any decision and action related to

possible changes to management system policy, objectives, targets and other elements of management system, consistent with the commitment to continual improvement

Designated Function

10. The minutes of the meeting shall be drafted and submitted for review and approval of the Designated Member of the Top Management preferably within five (5) working days after the review.


Management

11. Where necessary, the Designated Member of the Top Management shall verify relevant personnel questionable items in the minutes.

YES

NO

B

Review and approve minutes

Prepare/ Draft MR minutes for review and

approval

C

Convene and conduct the Management Review

A

Approved? C


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Management

12. Where applicable, the attendees of the Management Review shall be given each a copy of the minutes.

QMR 13. Highlights and/ or relevant information

about the management system and its performance shall be posted in the Bulletin for possible consultation.

All College/ Office

Heads 14. Issues and concerns relevant to the

College/ Offices shall be disseminated to the staff, and where needed, to the contractors.

15. Feedback shall be relayed to the QMR for

possible further action. QMR 16. The QMR shall be responsible in reporting

the overall management system status and concerns to the Top Management, particularly for concerns and initiatives requiring budgets or may affect university policies. The Top Management may also be informed of the status of the management system by the QMR during their regular review.

QMR or designated

function

17. Records of reviews, including decisions and actions taken shall be retained in accordance with the procedure on control of documented information.

QMR

END

Report progress on next Management

review

Follow-up action items

Reproduce and distribute Minutes

B


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6.0 ATTACHMENTS

6.1 Attachment A - Management Review Agenda

6.1.1 The agenda for the Management Review shall include but are not limited to the

following: 6.1.1.1 Status of actions from previous Management Review;

6.1.1.2 Changes in external and internal issues that are relevant to the QMS;

6.1.1.3 Information on the performance and effectiveness of the QMS, including

trends in: Customer satisfaction and feedback from relevant interested parties; The extent to which quality objectives have been met; Process performance and conformity of products and services; Nonconformities and corrective actions; Monitoring and measurement results; Audit results; The performance of external providers;

6.1.1.4 The adequacy of resources;

6.1.1.5 The effectiveness of actions taken to address risks and opportunities; and

6.1.1.6 Opportunities for improvement.

6.1.2 The above agenda need not be covered in a single meeting, but all of these must be discussed within each second tier QMS review cycle, i.e., one year.

7.0 FORMS

7.1 BulSU-SP-QMS-09F1, Management Review Minutes of Meeting

MANAGEMENT REVIEW MINUTES OF MEETING


Venue: Date Conducted:

A. Present during the meeting

Name Position College/ Office

B. Absent during the meeting (where appropriate, indicate reason for absence)


C. Other attendees during the meeting


D. Chaired by: Time Started:

E. Highlights of the Review

AGENDA / HIGHLIGHTS/ ACTION ITEM WHO/ WHEN (for action item only)

1. Status of actions from previous management reviews

2. Changes in external and internal issues that are relevant to the QMS, if any

3. Information on the performance and effectiveness of the QMS

a) Customer satisfaction and feedback from relevant interested parties b) Status of Quality Objectives/ OPCR





c) Process performance and conformity of products and services d) Progress of nonconformities and corrective action e) Monitoring, measurement, analysis and evaluation including status of action

taken, where applicable f) Fulfilment of compliance obligations including status of action taken, where

applicable g) Results of QMS audits (internal and external) and progress of actions taken h) Performance of External Providers

4. Adequacy of resources including allocation/ budget decisions, where applicable

5. Effectiveness of actions taken to address risks and opportunities

6. Relevant communications from interested parties including complaints and

status of action taken, where applicable

7. Opportunities for continual improvement including decisions and opportunities to improve integration of the QMS to business processes

8. Development and other circumstances that could affect the integrity of the QMS, including any decisions related to any need for changes to the QMS

9. Conclusions on the continuing suitability, adequacy and effectiveness of the QMS including the Quality Policy





10. Other matters

F. Time Adjourned: G. Tentative Date of Next Meeting:

Notes: If any of the above agenda is not applicable or there is no issue to review/ discuss for the period covered, this must be appropriately indicated against the relevant agenda. Prepared by:

QMR

Reviewed by:

Vice President for Finance, Administration

and Resource Generation

Reviewed by:

Vice President for Research, Extension and

Training

Reviewed by:


Reviewed by:

Vice President for Executive Operations

Approved by:

President


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NONCONFORMITY AND CORRECTIVE ACTION March 06, 2017

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QMR/ Director, IQAU





JAIME P. PULUMBARIT






1.0 OBJECTIVES

1.1 To provide guidelines for initiating and completing correction and corrective action to nonconformity in the management system; and

1.2 To ensure nonconformities in the management system are promptly identified, investigated and acted upon.

2.0 SCOPE 2.1 This procedure covers actual nonconformities relevant to the quality management system such

as but not limited to the following:

2.1.1 Internal/ External audit findings;

2.1.2 Product/ Service nonconformity resulting from monitoring and measurements;

2.1.3 Non-compliance to applicable laws and regulations and other requirements;

2.1.4 Objectives that are not achieved and/ or management programs that are not implemented as planned;

2.1.5 Decreasing trend in performance identified during data analysis;

2.1.6 Recurring/ Repeated nonconformity to established procedures and work instruction;

2.1.7 Valid customer complaints and concerns/ views from relevant interested parties;

2.1.8 Low rating in the Customer Satisfaction Survey; and

2.1.9 Problems identified during Management Review


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3.0 TERMS AND DEFINITIONS

3.1 Continual Improvement – recurring processes of enhancing the integrated management system

to achieve improvements in the overall performance of BulSU, in line with its quality policy

3.2 Correction – action taken to correct or stop or mitigate the impacts of a detected nonconformity or other undesirable and substandard condition.


3.4 Nonconformity – non-fulfillment of a requirement

4.0 REFERENCES


4.2 BulSU-SP-QMS-07, Monitoring Customer Satisfaction

4.3 BulSU-SP-QMS-08, Internal QMS Audit



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5.0 PROCEDURE 5.1 Corrective Action


Designated Function (Column B

of Table 1)

1. Actual nonconformities may be detected from: Internal and external audits: Monitoring & measurement of

processes/ products Customer Satisfaction Survey; Customer complaints Noncompliance to applicable legal and

other requirements; Management reviews

Designated

Function (Column B of Table 1)

2. Refer to Section 5.2 of this procedure for the nonconformities/ system improvement needing the initiation of System Improvement Request (BulSU-SP-QMS-10F1)

Designated


3. Details of the nonconformity shall be described in System Improvement Request (SIR). Refer to Section 5.2 of this procedure for the classification of nonconformity and/ or system improvements.

Designated


4. The SIR shall be accomplished within 5 working days upon detection of the actual nonconformity/ system improvement requirement.

A

Document Corrective Action

Identify actual nonconformity

START

H


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Designated


5. Where practicable and to save on paper and facilitate processing of Corrective Actions, only the initial issuance of the Corrective Action shall be printed and signed in hard copies by relevant functions. Succeeding processing (filling-out of sections A and B of the Corrective Action form) shall be done electronically and supplemented with Corrective Action Monitoring

Designated Function (Column B of Table 1)

6. The SIR shall be forwarded to the Document Controller for registration.

Document

Controller 7. The SIR shall be coded as:

YY-XX-00

Where: YY – last two digits of the calendar year; XX – nature of nonconformity; and 00 – counting number for issued Corrective Action per year

The Corrective Action shall be registered in the SIR Monitoring Form (BulSU-SP-QMS-10F2).

Designated


8. The registered SIR shall be issued to the designated function indicated in Column C of Table 1

B

Issue Corrective Action

Register SIR

A


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Designated Function (Column C

of Table 1)

9. If deemed appropriate, measures to stop/ correct the actual nonconformity or prevent its escalation or prevent it from worsening shall be applied immediately. If the problem would require action not within the capacity of the audited area/ function, the QMS Working Team may be consulted.

Designated

Function (Column D of Table 1)

10. Where the root cause of nonconformity is not readily known, a meeting may be initiated with the QMS Working Team.

Designated

Function (Column E of Table 1)

11. Corrective actions must adequately address the identified root causes of the nonconformity/ system improvement. Further, these shall be appropriate to the magnitude of the problem and commensurate with the risks associated with the nonconformity/ system improvement.

Designated


12. Long-term actions may be included in relevant Quality Management Programs. Refer to procedure in Setting-up, Review and Renewal of Quality Objectives and Programs (BulSU-SP-QMS-03).

C

Recommend corrective action

Investigate root cause(s)

D

Correct/ Mitigate on-going problem, if

applicable

B


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Designated


13. When corrective action results to a change in documented policy, procedure or work instruction, initiate a revision of the document in accordance with BulSU-SP-QMS-01

Note: Root cause analysis, proposal of corrective actions and risk assessment (if needed) shall be completed within 5 working days from the acknowledgment date of the Corrective Action.

Designated

Function (Column F of Table 1)

14. Review may also be conducted during weekly meetings, depending on the nature and magnitude of recommended action.

Management

Committee 15. Actions involving financial requirements of

more than the financial authority of the BulSU may require approval from the Management Committee. In which case, the issue may be reviewed and approved during management review

YES

NO Designated Function (Column F

of Table 1)

16. Where practicable, actions to prevent recurrence of the problem or actions for improvement shall be made available for consultation with the other key functions that may be affected.

E

Review recommended corrective action

C

D Approved?


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Document Controller

17. The Issuing Function shall forward the Corrective Action to Document Controller for updating of the SIR Monitoring Form. Brief description of the nonconformity, identified root cause(s), proposed corrective actions and target completion dates shall be recorded.

Designated

Function (Column G of Table 1)

18. Where necessary, a copy of the SIR shall be forwarded to relevant functions responsible for the implementation of corrective actions.

Designated

Function (Column H of Table 1)

19. The implementation of approved corrective action shall be verified within 5 working days after the committed completion date. Several follow-ups maybe made for multiple corrective actions

YES

NO Designated Function (Column H

of Table 1)

20. The completion dates may be extended if the reason for the delay is beyond the control of the function responsible for implementing the action. Otherwise, the Corrective Action shall be escalated to the next level of nonconformity/ system improvement and/ or forwarded to the next management level for appropriate action.

G

Verify implementation of agreed corrective action

Implement corrective action

F

Update SIR Monitoring

E

Implemented? F


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Designated Function (Column H

of Table 1)

21. The effectiveness of the corrective action taken shall be verified preferably after three months and not more than six months after the completion of the agreed action.

YES

NO Designated Function (Column H

of Table 1)

22. The corrective action taken shall be considered effective if the nonconformity does not recur within 3 – 6 months after the completion of the agreed actions. A new Corrective Action may be issued if the corrective actions taken are found to be ineffective.

23. Nonconformity that is similar to an existing

Corrective Action (issued within 3 months) may be referenced.

Designated

Function (Column H of Table 1)

24. Updated/ Completed SIR shall be forwarded to the Document Controller.

Document

Controller 25. The SIR Monitoring Form shall be

updated to reflect the status/ close- out of the Corrective Actions. The QMR shall be regularly informed and where necessary, a copy of the updated SIR Monitoring Form shall be provided at least quarterly.

Document

Controller 26. Changes resulting from the corrective

actions shall be appropriately integrated in the management systems and where necessary, shall be properly cascaded to the personnel.

Document

Controller/ QMR 27. Progress and effectiveness of SIR may

be discussed during operational meetings. Overall status and performance shall be discussed during management reviews.

END

Analyze and report progress of SIR

Update QMS

Close out SIR

Verify effectiveness of the corrective action

taken

G

H Effective?


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5.2 Guidelines in the issuance of SIR

5.2.1 SIR is not needed for:

5.1.1.1 Nonconforming product/ process that has been detected during monitoring

and measurement but was corrected by the process owner; hence correction forms part of the process per se;

5.1.1.2 Customer complaint or concern from external interested party which was found not valid; and

5.1.1.3 Observation and Hint for Improvement during internal audit which is only for

“verification during the next audit” or where the issue was immediately corrected as the audit is being conducted, or the required action is already on-going.

5.2.2 SIR is needed for: 5.1.1.4 Nonconformity identified during internal audit;

5.1.1.5 Objectives and targets that were not achieved at defined timeframe (e.g., at

the end of the year) or programs aimed at meeting objectives and targets that were not implemented as planned within a year;

5.1.1.6 Valid customer complaints or concerns from interested parties within the control of BulSU. Note: A single SIR shall be initiated for valid complaints of the same nature received at the same day. Where practicable, similar valid complaints may be referenced to an existing Corrective Action (not yet closed).

5.1.1.7 Repeated deviation (occurring more than three times within one running month) to management system policies, procedures, rules and guidelines, mainly detected by immediate superior;

5.1.1.8 Supplier/ Subcontractor with low (failed) rating during performance evaluation; and

5.1.1.9 Actual problem or deficiency identified during management reviews

5.3 Classification of management system nonconformity/ system improvement areas 5.3.1 Positive Findings – conformities to the management system which are commendable;

best practices that can be benchmarked by others. It could be in a form of award, achievement/ performance, attitude, etc.

5.3.2 Nonconformity – failure to fulfill a specified requirement of the standards

5.3.2.1 Major – (System Breakdown) total failure to fulfill a specified requirement of the standard that is applicable to the organization

a. Absence of documentation or non-implementation of the entire procedure

required by the International Standards;


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b. Where the nonconformity represents a repeating or widespread failure to implement the requirement of the QMS based on ISO 9001 Standard;

c. Failure to achieve QMS performance measures that can lead to an unacceptable risk and where BulSU has failed to take corresponding effective corrective action;

d. When a nonconformity is directly related to failure to recognize and record when an objective or target is not met or defined programs are not implemented as planned;

e. When a nonconformity is an immediate threat of delivering defective products; and

f. Aggregation of minor non-conformities

5.3.2.2 Minor – lapse in the system that has limited effect on the integrity of the

management system or environmental performance of the company such as the following:

a. Inconsistency in the implementation of a procedure

b. Non-implementation of some requirements of a procedure

c. Missing some documents, records, signature, incomplete data, etc.

5.3.3 Observation – An observation is not nonconformity but something that could lead to a

nonconformity, if allowed to continue uncorrected. It could also be an isolated lapse in the documentation or implementation of the management system which did not result to legal noncompliance and/ or injury or illness. Not directly limited to the requirements of the standards; and

5.3.4 Hints for Improvement – Conforming to the basic requirements of the management system standard or legal requirements, but can be further improved; findings which have no direct evidence of failure but are suspect in terms of long-term sustainability of the management system.


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This is a controlled document and must not be printed, photocopied without prior permission from the President and/ or QMR

6.0 ATTACHMENTS

Table 1 - Responsibilities for Handling/ Processing Corrective Action

(A) (B) (C) (D) (E) (F) (G) (H)

TYPE OF NONCONFORMITY ISSUED BY CORRECTED/

MITIGATED BY INVESTIGATED

BY

CORRECTIVE ACTION

DETERMINED BY

APPROVE CORRECTIVE

ACTION

FOLLOW-UP IMPLEMENTATION

FOLLOW-UP EFFECTIVENESS

1) Internal Audit findings (Nonconformity & Observation)

Auditor Head of Audited Function

Head of Audited Function

Head of Audited Function

Auditor/ QMR Auditor/ QMR Auditor/ QMR

2) Product/ Process NC detected during monitoring & measuring activities

QA/ QMR Designated Function in Relevant College/

Department/ Office

Designated Function in Relevant College/

Department/ Office

Designated Function in Relevant College/

Department/ Office

QMR QA/ QMR QA/ QMR

3) Valid customer complaints/ Low Customer Satisfaction Rating

QMR Relevant College/


Relevant College/


Relevant College/


QMR QMR QMR

4) Noncompliance to applicable legal requirements



Relevant College/


Relevant College/


QMR QMR QMR

5) Objectives that are not achieved



Relevant College/


Relevant College/


QMR QMR QMR

6) Poor supplier and service provider performance

Head, Procurement

Supplier/ Service Provider



Head, Procurement

Head, Procurement

Head, Procurement


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Table 1 - Responsibilities for Handling/ Processing Corrective Action

(A) (B) (C) (D) (E) (F) (G) (H)

TYPE OF NONCONFORMITY ISSUED BY CORRECTED/

MITIGATED BY INVESTIGATED

BY

CORRECTIVE ACTION

DETERMINED BY

APPROVE CORRECTIVE

ACTION

FOLLOW-UP IMPLEMENTATION

FOLLOW-UP EFFECTIVENESS

7) Recurring or repeated deviation from procedure/ WI

Relevant College/


Relevant Function/

Process Owner

Relevant Function/ Process Owner

Relevant Function/

Process Owner

Head, College/ Department/

Office

QMR QMR

8) Problems identified during Management Review



Relevant College/


Relevant College/


QMR QMR QMR

7.0 FORMS

7.1 BulSU-SP-QMS-10F1, System Improvement Request (SIR)

7.2 BulSU-SP-QMS-10F2, SIR Monitoring

SYSTEM IMPROVEMENT REQUEST (SIR)


SIR No:

Issue Date:

Issued by:

Issued to:

Signature Over Printed Name College/ Department/ Office/ Unit

CLASSIFICATION STANDARD/ PROGRAM CLAUSE(S) NATURE OF NONCONFORMITY

Nonconformity ISO 9001

Internal/ External audit finding [IA/ EA] Observation Others, please specify Legal non-compliance [LC]

Objectives not met [OB] Nonconformity to procedure/ WI [NI] Valid complaints from interested parties [CI] REFERENCE DOCUMENT, if any: Poor performance of external provider [PP]

Recurring system nonconformity [RS] Problems Identified during Management Review [MR] Others [OH]:

1) DESCRIPTION OF NONCONFORMITY/ OBSERVATION/ OTHER SYSTEM IMPROVEMENT

Acknowledged by: Noted by:

Signature Over Printed Name & Date Signature Over Printed Name & Date

2) MITIGATING MEASURE/ CORRECTION OF ONGOING ISSUE, if any

DESCRIPTION OF ACTION FUNCTION

RESPONSIBLE COMPLETION

DATE(S)

VERIFICATION (STATUS/BY WHOM/

DATE) [D, ND, OG]

Determined by: Approved by:


3) ROOT CAUSE(S)/ CONTRIBUTORY FACTORS OF NONCONFORMITY/ SYSTEM IMPROVEMENT



SYSTEM IMPROVEMENT REQUEST (SIR)


SIR No:

Issue Date:

4) AGREED CORRECTIVE ACTION



DATE(S)

VERIFICATION (STATUS/ BY WHOM/

DATE) [D, ND, OG]



5) SIMILAR NONCONFORMITY EXISTS/ OCCURS IN OTHER AREA/ PROCESS/ FUNCTION

YES NO If yes, complete below:

AREA/PROCESS/FUNCTION



DATE(S)

VERIFICATION (STATUS/ BY WHOM/

DATE) [D, ND, OG]

a.

b.

c.



6) REVIEW OF EFFECTIVENESS

DATE EVIDENCE OF EFFECTIVENESS EFFECTIVE? (YES/ NO)

REMARKS

Final Status of SIR: CLOSED RE-ISSUED New SIR No: Reviewed by: COMMENTS, if any:

Signature Over Printed Name & Date

Legends for Verification of Status (Auditor/ Designated Function):

D – Done/ Completed ND – Not done/ implemented OG – On-going

SYSTEM IMPROVEMENT REQUEST (SIR) MONITORING


SIR No. Date Initiator College/ Department/

Office Start Date Close Out Date Remarks