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Procedure: Work health and safety documentation management

Purpose

This procedure describes how the Australian National University (ANU) establishes, implements and maintains documentation for the work health and safety, rehabilitation and claims management systems (WHS). This procedure meets compliance requirements of the Work Health and Safety Act 2011 (Cth), the Work Health and Safety Regulations 2011 (Cth) and the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) (Cth). This WHS documentation procedure is based on the requirements in Australian Standards/New Zealand Standards (AS/NZS) 4801:2001, ISO19011:2018 and the National Audit Tool (NAT) for work health and safety. This procedure is linked to the University’s Work Health and Safety Policy and is one of the WHS Management System Procedures.

Definitions

Completed documentation refers to WHS forms, statements and reports which have open, editable fields that been filled out in entirety and are thus completed.

Documentation includes all WHS documents: forms, records and data required to meet WHS management system compliance. It is either electronic or in printed hardcopy.

National Audit Tool (NAT) requirements refers to the National Self Insurer WHS, Rehabilitation and Claims audit tool.

Metadata is 'data about data' that is stored with each page on the ANU website and in/on the Electronic Records Management System (ERMS). Metadata includes elements such as title, subject, and description. These elements are used by search engines to understand and rank pages, by end-users to verify and understand content, and by system administrators to manage the content within a website.

WHS Management System documents are any policies, procedures, guidelines or forms administered and managed by the Work Environment Group (WEG). Such documents are maintained in a WHS Management System document register.

The Work Health and Safety Management System (WHSMS) Handbook provides practical guidance for University and its local areas on how to implement the University WHS Management System and defines the responsibilities and actions required by management and workers within the management system.

Procedure

Scope

  1. This procedure applies to all documents, data and records generated to meet compliance with the WHS Management System. WHS documentation includes, but is not limited to:
  • the Safety Management System Manual and the Rehabilitation Management System Manuals;
  • WHS Management System documents (policies, procedures, guidelines and forms);
  • WHS Management System Handbook and associated templates, such as risk assessment template and safe work procedures;
  • audit reports, registers, plans and programs;
  • training records;
  • data collected for WHS monitoring;
  • notices and correspondence received from a regulatory body; and
  • other relevant documentation.

WHS Management System document design, implementation and maintenance

  1. All WHS Management System documents produced by the University will have a unique filename for identification. WHS documentation provided to the University by an external source is stored with a unique filename for identification.
  2. All WHS Management System documents are written using the relevant template and in accordance with the University writing style guide.
  3. All WHS Management System (WHSMS) documents are controlled in accordance with the Policy governance procedure and recorded in the WHS Legal and Other Requirements Matrix (used as the Management System document register). Each one will clearly state the document identification, version number and revision date.
  4. Detailed document control for different types of documents are specified as below:
  • WHSMS documents in Policy Library use the document control specified by Policy Library;
  • WHSMS documents in the WHSMS Handbook such as Chapters, templates and information sheets use the document control specified in the footer of each of the Chapter;
  • other documents such as Hazard and Risk Assessment and Safe Work Procedures that are created using WHSMS Handbook templates comply with the WHSMS Handbook document control format;
  • locally created WHS documents such as guidance materials or registers use the document control format specified in WHSMS Handbook; and
  • meeting agendas and minutes comply with the template format and document control specified by Digital Communications.
  1. All document controls specified above consist of the following as minimum:
  • title of the document;
  • responsible Officer and Approved by Position (Policy Library) or Approved by Person (WHSMS Handbook);
  • effective date (Policy Library) or release date (WHSMS Handbook);
  • review date; and
  • version number.

Approval and communication for WHS Management System documents

  1. Following consultation:
  • all WHS Management System documents in Policy Library, are approved per the Policy governance procedure;
  • all WHSMS Handbook Chapters are approved by Associate Director, Work Environment Group; and
  • other documents such as Hazard and Risk Assessment, Safe Work Procedures or locally created documents such as registers are approved by the position specified in WHSMS Handbook.
  1. Local WHS Committee Chairs ensure all relevant stakeholders and workers are notified of new WHS Management System documents or changes to documentation through relevant mediums.

Reviews and changes to WHS Management System documents

  1. WHS Management System documents are reviewed on a planned and unplanned basis. Planned reviews occur once every three years as per the Policy governance procedure .
  2. Changes can be requested at any time with Work Environment Group. Changes can also arise from incidents or as the result of audits, changes in legislation, business processes or other requirements.

Archiving and records

  1. WHS Management System documents that are superseded or repealed are removed from the accessible parts of the Policy Library or Health and Safety website and archived by the Policy Manager or Work Environment Group and recorded in the WHS Legal and Other Requirements Matrix (used as the Management System document register).
  2. All other WHS documentation is stored and archived in the Electronic Records Management System (ERMS) as per the Records and archives management policy and retained for the periods identified in each WHSMS Handbook Chapter (Examples are shown in Table 1). The responsibilities, disposal and access to records are defined in the Records and archive management procedure.
  3. All WHS Management System documents, associated procedures, risk assessments and safe work procedures will incorporate WHS legal and other requirements in accordance with ANU WHS Legal and Other Requirement Matrix.
  4. Examples of record management are listed in Table 1. Additional record management are specified in each WHSMS Handbook Chapter.

Table 1 Examples of Minimum retention periods for WHS documentation

WHS Documentation

Types

Minimum

Storage period

Action following retention period

Actions

Actions resulting from WHS processes (investigations, inspections, management reviews) and related completion evidence

10 years after the completion of the action

destroy

Audits

Audit reports, action trackers

10 years after all corrective actions completed

destroy

Communication

All types

7 years

destroy

Consultation

Consultation logs

Retain – No expiry

retain

Emergency Preparedness

Test results, action trackers

Retain

retain

Hazard

Hazard registers

Risk Assessments

Safe Work Procedures

10 years after the next review or in case of hazard registers, 10 years after entry

destroy

Incidents

Incident reports, claims reports, supporting documents, action trackers

No expiry

retain

Legal and other requirements

Legal and other requirements matrix, certificates of compliance, registration

7 years

destroy

Maintenance record of plant/equipment, infrastructure, safety devices and emergency facilities

All types

No expiry

retain

Management Review

Minutes

7 years

destroy

Monitoring

Monitoring records, Doctor’s certificates, calibration certificates, certifications, data

No expiry for health, 7 years for other

Health – retain

Others - destroy

Objectives, targets, plans and programs

Annual plans, annual objectives, annual WHS programs

10 years from the date of entry

destroy

WHS Management System documents

Policies, procedures, guidelines and forms

3 years

destroy

WHS advisory documents (Local areas)

Local area protocols or specific instructions

3 years


destroy

Permit to Work

All types

10 years after the permit ceases

destroy

Prestart Equipment Checklists

Vehicle, Forklift, Laboratory

No expiry

retain

Record of contractor engagement and compliance checks

All types

No expiry

retain

Reports

Annual Reports, internal reports (Council reports, WHS committee minutes)

10 years

destroy

Resources

Position descriptions, performance reviews, training records, training plans, qualifications

7 years

destroy

WHS Committee Meetings including Advisory Groups

Minutes, Agenda, Corrective Actions

10 years

destroy

WHS data and documentation management

  1. All WHS data and documentation is captured and stored in the University’s relevant enterprise management systems in accordance with WHSMS Handbook Chapter requirements.

Training and competency requirements

  1. There are no training requirements for the creation or for requesting of changes to WHS documentation. However, subject matter experts are involved in the review of WHS documentation.
  2. This procedure is further explained in and supplemented by WHSMS Handbook Chapter 5.2 Document Control and Record Management.

Sources

Refer to ANU WHS Legal and Other Requirements Matrix.

Information

Printable version (PDF)
Title Work health and safety documentation management
Document Type Procedure
Document Number ANUP_015811
Version 3
Purpose This procedure describes how the Australian National University (ANU) establishes, implements and maintains documentation for the work health and safety, rehabilitation and claims management systems (WHS).
Audience Staff
Category Administrative
Topic/ SubTopic Health, Safety & Environment - Occupational Health & Safety
 
Effective Date 20 Sep 2021
Review Date 20 Sep 2026
 
Responsible Officer: Director, Human Resources
Approved By: Chief Operating Officer
Contact Area Human Resources Division
Authority: Work Health & Safety Act 2011
Work Health and Safety Regulations 2011
Delegations 0