EMS Gap Analysis QuestionnaireSAFETYSENSE CONSULTING NIG
LTDISO 14001 Gap Analysis QuestionnaireFacility name:Contact
Person:Facility Address:Email:Phone:Conducting the EMS Gap
AnalysisObjectivesThe ISO 14001 Standard is internationally
recognized and used by industry and government organizations to
enhance environmental and operational effectiveness, efficiency,
and performance. Conducting an EMS gap analysis is a key step in
developing and implementing an ISO 14001 EMS. The objectives of
this step include: Assisting select Areas and facilities in
determining how their environmental management system compares to
the 17 elements of the ISO 14001 EMS Standard, and Improving EMS
assessment tools and guidance to ensure practicality and compliance
with environmental requirements and other relevant requirements.Gap
Analysis BackgroundThe EMS gap analysis is a self-evaluation. A
series of questions will help you compare your organizations
current environmental management practices against the ISO 14001
Standard. This comparison provides a baseline assessment of your
organization and helps you to identify current systems in place for
managing environmental issues, including existing policies and
procedures, roles and responsibilities, communication systems,
training programs and others.Gap Analysis Questionnaire Description
and DirectionsThe bulk of the questionnaire addresses the ISO 14001
requirements. There are 17 short sections of questions that
correspond to the 17 EMS elements. The 17 sections fall under the
five main EMS categories of environmental policy; planning;
implementation and operations; corrective action; and management
review. Each of the sections are labeled with the EMS element
number so you can easily reference additional information about the
17 elements of the Standard.There are three check boxes to the
right of each of the questions on the Gap Analysis Questionnaire.
After you respond to each question, place an "X" or a check in the
block that best describes the status of the component as it relates
to your EMS. The status blocks in the gap analysis tool are
represented as follows:StatusNot in placePartially in placeIn
PlaceXA numerical rating measuring your organizations conformance
to the ISO 14001 Standard is determined from the responses on this
questionnaire. A numerical rating is given for each component
response as follows:Not in place = 0 points Partially in place = 1
point In place = 2 pointsThe responses are totaled for the entire
questionnaire resulting in your score. The highest score possible,
172, indicates all components of the 17 elements are In place in
your EMS (85 questions/components x 2 points for each component In
place = 170 points). This baseline assessment enables you to focus
on continual improvement. In the electronic version of the EMS Gap
Analysis Questionnaire provided with the EMS Toolkit, the second
tab titled "Summary Chart", contains a bar chart to give you a
visual depiction of the degree to which you conform to the ISO
14001 EMS Standard. This chart can be used in management
presentations to show the progress of your EMS
implementation.Hints1) List of Required Documentation and Records:
The ISO 14001 EMS Standard requires physical (or electronic)
evidence of certain documents and records. This includes, for
example, the organization's environmental policy. There is a list
at the end of this gap analysis questionnaire that highlights which
items require physical (or electronic) evidence in the form of
documentation or records. The list is organized by each of the 17
elements in the Standard. Elements of the ISO 14001 EMS Standard
that require documentation are indicated in bold text in the gap
analysis questionnaire for easy reference to the requirements of
the Standard.2) List of Reference Material: The second part of the
list at the end of this gap analysis questionnaire is a list of
reference materials you may already possess that could help you
identify your current EMS status. This list is organized by each of
the 17 elements of the Standard.Question Category: Environmental
PolicyEMS Element 1: Environmental Policy (ISO 14001:2004(E),
Paragraph 4.2)Indicators of ConformityStatusFinding / Corrective
ActionNotesNot in placePartially in placeIn place1.Has top
management defined the organization's environmental policy?2.Does
your procedure (process) for the environmental policy ensure that
the policy is appropriate to the nature, scale and environmental
impacts of its activities, products, and services that are within
the defined scope of your environmental management system?3.Does
your environmental policy within the defined scope of your EMS
commit to continual improvement and prevention of pollution?4.Does
your environmental policy within the defined scope of your EMS
commit to complying with applicable environmental legal
requirements and other environmental requirements?5.Does your
procedure (process) for the environmental policy provide a
framework for setting and reviewing environmental objectives and
targets?6.Does your procedure ensure that the environmental policy
is documented, implemented, and maintained?7.Does your procedure
(process) for the environmental policy communicate the policy to
all persons working for or on behalf of the organization?8.Does
your procedure (process) for the environmental policy make the
policy available to the public?Is the policy consistent with other
corporate policies affecting the business?Status
subtotals:000Status Total:016 points availablePercentage
complete:0Question Category: PlanningEMS Element 2: Environmental
Aspects (ISO 14001:2004(E), Paragraph 4.3.1)Indicators of
ConformityStatusFinding / Corrective ActionNotesNot in
placePartially in placeIn place9.Does your procedure (process) for
environmental aspects address: Identifying environmental aspects of
activities, products, and services within the defined scope of the
EMS that it can control and those which it can influence taking
into account planned or new developments, or new or modified
activities, products and services?10.Determining those aspects that
have or can have significant impact on the
environment?11.Maintaining a documented up-to-date list of all
aspects including those that are significant?12.Ensuring that
significant environmental aspects are considered in developing,
implementing and maintaining the EMS?Is there a risk assessment
process to determine significance or priority of identified
environmental aspects/impacts?Status subtotals:000Status Total:08
points availablePercentage complete:0EMS Element 3: Legal and Other
Requirements (ISO 14001:2004(E), Paragraph 4.3.2)Indicators of
ConformityStatusFinding / Corrective ActionNotesNot in
placePartially in placeIn place13.Does your procedure (process) for
environmental legal and other environmental requirements address:
Identifying applicable legal requirements related to your
organization's environmental aspects? Accessing applicable legal
requirements related to your organization's environmental aspects?
Determining how the legal requirements apply to your organization's
aspects? Identifying other environmental requirements to which your
organization subscribes? Accessing other environmental requirements
to which your organization subscribes? Determining how other
environmental requirements to which your organization subscribes
apply to your organization's aspects?14.Does your procedure ensure
that environmental legal and other environmental requirements to
which the organization subscribes are considered in developing,
implementing and maintaining your organization's environmental
management system?Status subtotals:000Status Total:014 points
availablePercentage complete:0EMS Element 4: Objectives, Targets
and Programme(s) (ISO 14001:2004(E), Paragraph 4.3.3)Indicators of
ConformityStatusFinding / Corrective ActionNotesDoes your procedure
(process) for Objectives, Targets and Programmes address:Not in
placePartially in placeIn place15.Establishing and maintaining
documented environmental objectives and targets at relevant
functions and levels within the organization?16.Establishing
measurable objectives and targets, where practicable, that are
consistent with the environmental policy, including the commitments
to prevention of pollution, compliance with legal and other
environmental requirements and continual improvement?17.The legal
and other environmental requirements, its significant environmental
aspects, its technology options and its financial, operational and
business requirements and the views of interested parties when
establishing and reviewing objectives and targets?18.Does your
procedure (process) address establishing and maintaining programs
for achieving your organization's objectives and targets, including
designating responsibility for achieving objectives and targets at
relevant functions and levels of your organization?19.Does your
procedure (process) address establishing and maintaining programs
for achieving your organization's objectives and targets, including
the means and time-frame by which the objectives and targets are to
be achieved?Have specific environmental improvement objectives been
communicated to all relevant business units and employees,
contractors and suppliers?Determine whether the facility has
prepared and implemented sufficient written policies and procedures
to ensure compliance with applicable standards and consistency in
implementation practices, and to provide guidance on how to meet
applicable standards.Confirm that the facility has established
compliance standards to be followed that are reasonably capable of
reducing the prospect of criminal conduct.Verify, where possible,
that the facility has taken steps to achieve compliance with its
environmental standards.Verify that the facility has a program in
place to review the full range of capital projects, maintenance
modifications, process changes, and R&D initiatives to identify
potentially significant consequences.Determine if these review are
performed in a timely manner, by appropriately trained
professionals and if a formal methodology is employed.Status
subtotals:000Status Total:010 points availablePercentage
complete:0Question Category: Implementation and OperationEMS
Element 5: Resources, roles, responsibility and authority (ISO
14001:2004(E), Paragraph 4.4.1)Indicators of
ConformityStatusFinding / Corrective ActionNotesDoes your procedure
(process) for resources, roles, responsibility and authority
address:Not in placePartially in placeIn place20.Management
ensuring the availability of resources (human resources &
specialized skills, internal infrastructure, technology and
financial resources) essential for the implementation and control
of the environmental management system?21.Defining, documenting and
communicating the roles, responsibilities and authorities to
facilitate effective environmental management?22.Top management
appointing a specific management representative who, irrespective
of other responsibilities, has defined responsibilities and
authority for: Ensuring that an environmental management system is
established, implemented, and maintained in accordance with the
requirements of ISO 14001? Reporting on the performance of the
environmental management system to top management for review and as
the basis for improvement?Verify if the roles and responsibilities
cover: Legal/regulatory tracking; Updating/reviewing documentation
control procedures; Training; Policy and procedure development;
Contractor oversight; Follow-up to inspections/audits/periodic
reviews; Updating the environmental policy; Identifying
environmental aspects/impacts of on-site operations; and,
Responding to external requests for information.Verify that the
roles are clearly defined, documented, and understood and that
there are no redundancies or gaps in the coverage.Interview staff
from various operating departments to confirm that environmental
roles and responsibilities are clearly understood within the
facility.Status subtotals:000Status Total:08 points
availablePercentage complete:0EMS Element 6: Competence, training
and awareness (ISO 14001:2004(E), Paragraph 4.4.2)Indicators of
ConformityStatusFinding / Corrective ActionNotesDoes your procedure
(process) for competence, training and awareness address:Not in
placePartially in placeIn place23.Identifying training needs to
ensure that any person(s) performing tasks on the organization's
behalf that have the potential to cause (a) significant
environmental impact(s) identified by the organization is/are
competent on the basis of appropriate education, training, or
experience?24.Identifying training needs associated with the
organization's environmental aspects and its EMS? Providing
training or taking other actions to meet these needs?25.Making
persons working for the organization or on its behalf aware of: The
importance of conformity with the environmental policy and
procedures and with the requirements of the environmental
management system? The significant environmental impacts, actual or
potential, of their work and the environmental benefits of improved
personal performance? Their roles and responsibilities in achieving
conformity with the environmental policy and procedures and with
the requirements of the environmental management system, including
emergency preparedness and response requirements? The potential
consequences of departure from specified operating procedures?The
scope of training includes: Emergency response and preparedness;
The importance of complying with established performance criteria
and the potential consequences of departure from specified
environmental operating procedures; Adequate detail to motivate
personnel to prevent, detect, and correct violations; and, The
facility offers all staff an opportunity to attend internal
environmental training sessions.Identify a sample of facility
personnel who perform tasks that can cause significant
environmental impact.Verify that these staff members have received
appropriate environmental training relative to the job
functions/tasks performed.Confirm that the facility promotes
environmental awareness through periodic memoranda, use of bulletin
boards, environmental newsletters, award programs, etc.Confirm
whether staff with environmental responsibilities have the relevant
background, training, and capabilities to effectively carry out
their responsibilities.Status subtotals:000Status Total:012 points
availablePercentage complete:0EMS Element 7: Communication (ISO
14001:2004(E), Paragraph 4.4.3)Indicators of
ConformityStatusFinding / Corrective ActionNotesDoes your procedure
(process) for Communication address:Not in placePartially in
placeIn place26.Establishing and maintaining procedures for
internal communication between the various levels and functions of
your organization with regard to your organization's environmental
aspects and environmental management system?27.Establishing and
maintaining procedures for receiving, documenting, and responding
to relevant communication from external interested parties with
regard to your organization's environmental aspects and
environmental management system?28.The organization's decision on
whether to communicate externally on its significant environmental
aspects and the documentation of that decision?If the decision is
to communicate externally on its significant environmental aspects,
does the organization have a method(s) for this external
communication?Status subtotals:000Status Total:08 points
availablePercentage complete:0EMS Element 8: Documentation (ISO
14001:2004(E), Paragraph 4.4.4)Indicators of
ConformityStatusFinding / Corrective ActionNotesNot in
placePartially in placeIn place29.Does your environmental
management system documentation include: An environmental policy,
objectives and targets for your organization?- a description of the
scope of the environmental management system? A description of the
main elements of the environmental management system and their
interaction and reference to related documents? Documents and
records required by the ISO 14001 Standard (at minimum those bolded
in this gap analysis tool)? Documents and records the organization
determined necessary to ensure the effective planning, operation
and control of processes that relate to its significant
environmental aspects?Status subtotals:000Status Total:010 points
availablePercentage complete:0EMS Element 9: Control of Documents
(ISO 14001:2004(E), Paragraph 4.4.5)Indicators of
ConformityStatusFinding / Corrective ActionNotesNot in
placePartially in placeIn place30.Does your document control
procedure(s) address the need to control documents required by the
environmental management system and by the International
Standard?31.Does your document control procedure(s) address the
need to: Approve documents before they are issued? Review and
update them as necessary, and re-approve them before reissuing
them? Ensure changes and the current revision status of documents
are identified? Ensure current documents are available at points of
use? Ensure documents are legible and easily identifiable? Ensure
that external documentation you deem necessary for the planning and
operation of the environmental management system are identified and
their distribution controlled? Ensure obsolete documentation is not
unintentionally used? Identify obsolete documentation if it needs
to be retained for any purpose?Evaluate whether: There are systems
in place to ensure that all required reports are sent to regulators
in a timely fashion; The documentation/records system clearly
identifies the maintenance retention period, and disposition of
records; and, Employees have access to environmental documents they
need to conduct job activities.Status subtotals:000Status Total:018
points availablePercentage complete:0EMS Element 10: Operational
Control (ISO 14001:2004(E), Paragraph 4.4.6)Indicators of
ConformityStatusFinding / Corrective ActionNotesDoes your procedure
(process) for Operational Controls:Not in placePartially in placeIn
place32.Identify those operations that are associated with the
identified significant environmental aspects consistent with your
organization's environmental policy, objectives and
targets?33.Establish and maintain documented procedures to control
situations for those operations where absence of documented
procedure(s) could lead to deviation from your environmental
policy, objectives and targets?34.Plan these operations in order
that they are carried out under specific conditions, stipulate
operating criteria, establish, implement and maintain environmental
procedures related to goods and services used by the organization
and communicate applicable requirements to suppliers and
contractors?Status subtotals:000Status Total:06 points
availablePercentage complete:0EMS Element 11: Emergency
preparedness and response (ISO 14001:2004(E), Paragraph
4.4.7)Indicators of ConformityStatusFinding / Corrective
ActionNotesDo you establish and maintain a procedure (process) for
emergency preparedness and response that addresses how to:Not in
placePartially in placeIn place35.Identify potential emergency
situations and potential accidents that can have (an) impact(s) on
the environment and how the organization will respond?36.Respond to
actual emergency situations and accidents and prevent or mitigate
associated environmental impacts?37.Does your organization
periodically review and, where necessary, revise the emergency
preparedness and response procedures, in particular, after the
occurrence of accidents or emergency situations?38.Does your
organization periodically test the emergency preparedness and
response procedures where practicable?Confirm that the procedures
have been updated, as appropriate, in response to new information
or program reviews.Status subtotals:000Status Total:08 points
availablePercentage complete:0Question Category: CheckingEMS
Element 12: Monitoring and measurement (ISO 14001:2004(E),
Paragraph 4.5.1)Indicators of ConformityStatusFinding / Corrective
ActionNotesDo you establish and maintain a procedure (process) for
monitoring and measurement that ensures:Not in placePartially in
placeIn place39.Key characteristics of your operations (that can
have a significant environmental impact) are monitored and measured
on a regular basis?40.Information is documented to monitor
performance, applicable operational controls, and conformity with
the objectives and targets of your organization?41.Monitoring and
measurement equipment is calibrated and maintained and all
associated records are retained?Status subtotals:000Status Total:06
points availablePercentage complete:0EMS Element 13: Evaluation of
compliance (ISO 14001:2004(E), Paragraph 4.5.2)Indicators of
ConformityStatusFinding / Corrective ActionNotesNot in
placePartially in placeIn place42.Does your procedure (process) to
meet the organization's commitment to compliance ensure that you
periodically evaluate compliance with applicable environmental
legal requirements and other environmental requirements to which
the organization subscribes?Status subtotals:000Status Total:02
points availablePercentage complete:0EMS Element 14: Nonconformity,
corrective action and preventive action (ISO 14001:2004(E),
Paragraph 4.5.3)Indicators of ConformityStatusFinding / Corrective
ActionNotesNot in placePartially in placeIn place43.Do you
establish and maintain a procedure (process) for controlling
non-conformities and taking corrective and preventive
actions?44.Does the procedure for controlling non-conformities and
taking corrective and preventive action ensure that: Actual
non-conformity(-ies) are identified and corrected and their
environmental impact(s) are mitigated? Actions are taken to
investigate and eliminate the causes of nonconformities so that
they do not occur again? Actions are determined to eliminate the
causes of potential non-conformities and to prevent their
recurrence?45.Are any measures taken to identify, correct,
mitigate, prevent or eliminate the nonconformity(-ies) consistent
with the magnitude of the problems and the environmental impacts
encountered?46.After corrective and preventive actions have been
taken, are they reviewed and the program adjusted accordingly by
implementing and documenting any new changes that result from the
findings?Status subtotals:000Status Total:012 points
availablePercentage complete:0EMS Element 15: Control of Records
(ISO 14001:2004(E), Paragraph 4.5.4)Indicators of
ConformityStatusFinding / Corrective ActionNotesNot in
placePartially in placeIn place47.Has your organization created and
maintained records as necessary that demonstrate compliance with
the EMS and conformance to the requirements of the ISO 14001
Standard, including evaluation of compliance with environmental
legal requirements and other environmental requirements to which
the organization subscribes and the implementation of procedures
and results achieved?48.Does your procedure (process) for records
management describe how the records will be identified, stored,
protected, retrieved, retained, and disposed?49.Are the records
themselves legible, identifiable, and traceable?Status
subtotals:000Status Total:06 points availablePercentage
complete:0EMS Element 16: Internal audit (ISO 14001:2004(E),
Paragraph 4.5.5)Indicators of ConformityStatusFinding / Corrective
ActionNotesDoes your procedure (process) for an internal
environmental management system audit:Not in placePartially in
placeIn place50. Ensure that internal environmental management
system audits are conducted at planned intervals? Determine whether
the environmental management system conforms to planned
arrangements for environmental management including the
requirements of the ISO 14001 Standard? Determine whether the
environmental management system has been properly implemented and
is maintained? Determine whether the environmental management
system provides information on the results of audits to
management?51.Plan, establish and maintain the environmental
management audit program taking into consideration the
environmental importance of the operation(s) concerns and the
results of previous audits?52. State the responsibilities and
requirements for planning and conducting audits? State the
responsibilities and requirements for reporting results? Define the
audit criteria, scope, frequency and methods and explain how you
have determined them?53.Ensure that the selection of auditors and
the conduct of the audits maintains the objectivity and
impartiality of the audit process?Status subtotals:000Status
Total:018 points availablePercentage complete:0Question Category:
Management ReviewEMS Element 17: Management review (ISO
14001:2004(E), Paragraph 4.6)Indicators of ConformityStatusFinding
/ Corrective ActionNotesDoes your procedure (process) for
Management Review:Not in placePartially in placeIn place54.Ensure
continuing suitability, adequacy, and effectiveness of the
environmental management system through top management review of it
at planned intervals?55.Ensure that opportunities are assessed for
improvement and the need for changes to the environmental
management system including the environmental policy and
environmental objectives and targets are assessed?Ensure that the
results of the management reviews are documented?56.Contain input
which includes the following: results of environmental management
system audits, communication from external interested parties, the
performance of the environmental management system, the extent to
which objectives and targets have been met, status of corrective
and preventive actions, follow-up actions from previous management
reviews, changing circumstances, and recommendations for
improvement?57.Ensure that the outputs from the management review
include any decisions and actions related to possible changes to
the environmental policy, objectives and other elements of the
environmental management system, consistent with the commitment to
continual improvement?Confirm that a review process exists to
update the policy and to communicate changes to appropriate
stakeholders.Status subtotals:000Status Total:010 points
availablePercentage complete:0Program TotalsElement
subtotals:000Program Total:0172 points availableTotal Program
percentage complete:0Required Documents and RecordsReference
MaterialsElement 1: Environmental Policy- Organization's
Environmental Policy- Environmental PolicyElement 2: Environmental
Aspects- List of significant aspects- Results of environmental
aspects identification process- List of all aspects- List of
critical business functionsElement 3: Legal and Other Requirements-
Laws, regulatory and other code requirements- Voluntary standard
agreementsElement 4: Objectives and Targets- Environmental
objectives and targets- List of performance measures for
decontaminations process- List of programs associated with
significant aspects- Wastewater management plan- Hazardous
management plan- Chemical management plan- Process Safety
management- Bloodborne pathogens program- Communications
programElement 5: Resources, roles, responsibility and authority-
Roles, responsibilities, and authorities for the environmental
management system- Job descriptions for key on site staff for
programs to address significant aspects- Budgets- Work schedules-
Organizational charts- Staffing assignmentsElement 6: Competence,
training and awareness- Training material and sign up sheets- Shift
change meeting notes- Training records- Resumes of staff
responsible for key programs- Roster of fully equipped and trained
emergency personnel with the authority to perform essential
functions and activitiesRequired Documents and RecordsReference
MaterialsElement 7: Communication- The organization's decision
whether to communicate their environmental aspects externally- Key
presentations- Newsletters- Town meeting presentations- PR
releases- Web based information- Communications with customers,
suppliers, contractors and other external parties- Correspondence
with management- Master call list for employees- Internal
communication procedure- External communication procedure- Sample
scriptElement 8: Documentation- Documents and records determined by
the organization to be necessary to ensure the effective planning,
operation and control of processes that relate to its significant
environmental aspects- Description of the main elements of the EMS
and their interaction and reference to related documentsElement 9:
Document Control- List of key documents- Legal documents-
PermitsElement 10: Operational Control- Operational Control
Procedures- Procedures for different media(where the absence of
documented procedures could lead to deviation from the- Contactor
environmental plansenvironmental policy and the objectives and
targets)- Operational controls- Sampling procedures- Preventative
maintenance plan for equipmentElement 11: Emergency preparedness
and response- Site emergency response plan- Incident notification
procedure- Organization evacuation procedure- Employee meeting and
disbursement procedureRequired Documents and RecordsReference
MaterialsElement 12: Monitoring and measurement- Records associated
with calibration and maintenance of monitoring and measurement
equipment- Records of monitoring and measurements- Information to
monitor performance, applicable operational controls and conformity
with the organization's environmental objectives and targets-
Reports of progress toward meeting objectives and targets-
Monitoring equipment calibrations- Accident investigation reports-
Injury and illness reports- Permits, licenses and other
approvalsElement 13: Evaluation of legal compliance- EMS audit and
regulatory compliance audit reportsElement 14: Nonconformity and
preventative and corrective action- New changes to the program
resulting from findings once the corrective and preventive actions
have been taken- Reports of identified nonconformance, corrective
action plans and corrective action tracking- Reports of hazardous
material spills or other environmental incidentsElement 15:
Records- Records as necessary to demonstrate conformity to the
requirements of the EMS and of the International Standard.-
Training, environmental management audit and management review-
Sampling and monitoring data- Equipment maintenance records- Record
retention policy- Vital legal and financial records (accounts
receivable; contracting and acquisition files; official personnel
files: social security, payroll, retirement, and insurance records;
and property management and inventory records)- Logs and notes for
emergency response exercisesElement 16:Internal environmental
management system audit- Self assessments- Environmental management
audit reportsElement 17: Management review- Results of management
reviews- Senior managers meeting minutes- Change to environmental
management system- Results of management review
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Summary Chart1Environmental Policy2Environmental Aspects3Legal
and Other Requirements4Objectives, Targets and Programs5Resources,
Roles, Responsibility and Authority6Competence, Training and
Awareness7Communication8Documentation9Control of
Documents10Operational Control11Emergency Preparedness and
Response12Monitoring and Measurement13Evaluation of
Compliance14Nonconformity, Corrective Action and Preventive
Action15Control of Records16Internal Audit17Management Review