OHS Self-audit Questionnaire
AS/NZS 4801
OHSAS 18001
OHS20309
SAI Global
Introduction
This self-audit questionnaire is based on mandatory elements of the Monash University OHS Management System (OHSMS) and the implementation and monitoring requirements of OHS
Standards OHSAS 18001:2007 & AS/NZ 4801:2001. The purpose of this self-auditing tool is for each area to assess their own level of implementation of the OHSMS and to develop corrective
actions to ensure continual improvement of health and safety at a local level. The OHS Self-audit questionnaire must be completed annually by each academic/administrative unit.
How to use
1.
2.
ALL AREAS must complete: Section A: General OHS Management requirements [Q1 – Q52]
Areas that use laboratories, studios or workshops in their teaching, research or work activities should complete:
Section B if they use machinery or equipment [Q53 - Q60]
Section C if they use chemicals [Q61 – Q76]
Section D if they use gas cylinders [Q77 – Q80]
Section E if they use lasers [Q81 – Q86]
Section F if they use radioactive substances, sources and apparatus [Q87– Q 97]
Section G if they use biological substances [Q98 – Q102]
Section H if they use animals [Q103 – Q106]
3.
All OHS documents mentioned in this questionnaire are available from the Occupational Health and Safety unit website located at www.monash.edu.au/ohs/topics/index.html. A list of OHS
Consultants/Advisors for all university areas is available at: www.monash.edu.au/ohs/contacts/ohs-branch.html.
Details
Organisational Unit:
Date:
Audited by:
Signature/s:
Safety Officer:
Signature:
Head of Unit:
Signature:
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 1 of
14/01/2015
A. General OHS Management Requirements
OHS Planning
Q1.
Does your unit have a current Occupational Health and Safety plan?
Yes
No
Q2.
Is a dedicated budget allocated for OHS programs?
Yes
No
Yes
No
The Monash University Health and Safety Committee requires that each Faculty/Division
creates an annual plan to ensure OHS is integrated into planning and to enable
continuous improvement by aligning areas with the Monash University OHS
Management System.
Senior Management must provide adequate budgetary resources to ensure the unit's
OHS objectives can be met.
Roles and Responsibilities
Q3.
Is there a Safety Officer appointed for the unit?
Please name:
The safety officer forms an important link between Occupational Health and Safety, the
unit's management group, staff and students. They are the employer’s representative(s)
in relation to the Victorian OHS Act 2004, s. 73 (2).
The safety officer is the head of unit's nominee for health and safety matters within the
unit and assumes a critical role in ensuring OHS is managed in a proactive manner.
In the absence of an appointed safety officer, the relevant head of
academic/administrative unit assumes the responsibilities of the safety officer
(Section 5.3 of 'OHS Roles, Committees and Responsibilities').
Q4.
Is there a Health and Safety Representative elected for the
designated work group (DWG) to which the unit belongs?
Yes
No
Yes
No
Please name:
Q5.
Has a First Aid Coordinator been appointed to your unit?
Please name:
Self Audit Questionnaire, v7
Date of first issue: June 2005
A health and safety representative is an employee representative who has been elected
by the staff in the designated work group to represent their health and safety interests
using the procedures outlined in the Monash University 'Procedures for health and
safety issue resolution'.
A health and safety representative represents all staff in a DWG and is an elected
position defined under the Victorian OHS Act 2004.
The statutory powers of health and safety representatives are outlined in Division 5, Part
7, of the Act and include: the right to direct work to cease where there is an immediate
threat to the health and safety of any person; the right to inspect any part of the
workplace at which a member of the DWG works, at any time giving reasonable notice to
the relevant unit head and immediately in the event of an incident or hazardous situation;
and the right to be consulted, if practicable, on any proposed changes in the workplace
that may affect the health and safety of staff.
Please note: There is no obligation to elect a health and safety represetatvie if the
members of the DWG do not feel one is required.
First aid coordinators act as the focal point for communication between first aiders in the
work area and OH&S.
First Aid Coordinator responsibilities are outlined in Section 5.4.3 of OHS Roles,
Committees and Responsibilities'.
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 2 of
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Q6.
Has a building warden been appointed for all buildings in which your
unit is located?
Yes
No
OHS responsibilities of the building warden are outlined in OHS Roles, Committees
and Responsibilities'
Please name:
Building Address:
Q7.
Please name:
Building Address:
Have specific OHS responsibilities been included in the position
descriptions, engagement profile or performance development plan
of staff with the following safety roles:








Q8.
To ensure the safety personnel have their roles appropriately recognised and rewarded,
the role/duties should be reflected in their position description, engagement profile or
performance management documentation.
OHS roles in position descriptions (pdf 108kb)
Biosafety officers
Building wardens
Yes
No
First aiders and first aid coordinators
Health and safety representatives
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
No
Laser safety officers
Mental Health First Aider
Radiation safety officers
Safety officers
Have specific OHS responsibilities been included in the position
descriptions, engagement profile or performance development plan
of supervisory and management staff?


Senior management
Supervisors
Safety personnel must also be provided with appropriate training to carry out their
responsibilities; this also must be added to the relevant section of the Monash HR
performance management documentation.
OHS responsibilities, accountabilities and obligations of managers and supervisors or
both academic and professional staff are outlined in OHS roles in position
descriptions (pdf 108kb).
Yes
No
Yes
No
Communication and Consultation: How is OHS communicated across your area?
Q9.
Is OHS a standing agenda item at all work area meetings?
Yes
No
Q10.
Are staff and students in your area notified of local OHS committee
meetings?
Yes
No
Yes
No
Q11.
Do staff and students receive requests for agenda items for OHS
committee meetings?
Self Audit Questionnaire, v7
Date of first issue: June 2005
A clear demonstration of the incorporation of OHS as a core management responsibility
is the active inclusion of OHS as a regular agenda item at meetings.
OHS Communication Procedure
In each area of the University, health and safety issues are managed by a local OHS
committee. OHS committees are chaired by a senior academic or professional staff
equivalent and include representatives from the various work groups within the area.
OHS committees are required to meet at least quarterly. Their main responsibility is to
provide a consultative forum for the discussion, resolution and implementation of OHS
issues and the formulation of local practices that promote OHS within their area.
OHS committee meetings are a forum for discussion of OHS issues, notice of each
meeting must be circulated to the staff and students in the area, requesting agenda
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 3 of
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items and/or issues for discussion. Items submitted must be included on the agenda of
the next meeting and the proposer invited to the meeting for the discussion of the item.
Q12.
Are minutes of OHS meetings made accessible to all staff and
students?
Q13.
Are the following documents displayed on work area notice boards?






Q14.
Monash University OHS policy
Health & safety issue resolution procedural flowchart?
Lists of first aiders & emergency wardens?
“If you are injured” poster from the Victorian WorkCover
Authority (VWA)?
Name and contact details of HSR (if applicable) and
Other local Safety personnel
Does your work area follow the Monash University OHS procedures
for consultation?
Yes
No
Minutes of meetings must be kept and made accessible to all staff and postgraduate
students (e.g. copies on safety notice boards, in the lunch room, circulated electronically
and/or on a website).
To promote general awareness of OHS across the University, all units are to display the
current OHS policy within the work area. Staff and/or student noticeboards or safety
specific noticeboards are promoted as the best place to display the OHS policy. Section
6.4 OHS Communication Procedure
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
No
No
Displaying the “If you are injured at work” poster is a requirement of the Accident
Compensation Act 1985 s.101. Copies can be obtained from the Occupational Health
and Safety Unit.
Yes
No
In accordance with the Victorian OHS Act 2004 s. 35(1), staff must be consulted:
 during risk management;
 when making decisions regarding facilities related to welfare, e.g. toilets, first aid;
 during development of OHS policies and procedures;
 when changes are proposed to the workplace, new buildings and renovations,
machinery/equipment, substances, processes and other things used in the workplace
or the work performed that may affect the health and safety of staff.
The OHS issue resolution flowchart is on Page 3, Section 5 of the linked procedure.
The Monash University 'Procedures for OHS consultation' outline consultation
procedures to be followed by units. Units must also develop internal procedures to
ensure that staff are involved in the risk management process.
OHS Induction
Q15.
Do all staff complete the online Monash Safety induction?
Yes
No
Q16.
Do all HDR students complete the online Monash Safety induction?
Yes
No
OHS induction at Monash University is split into two mandatory programs - the online
general induction and the local area induction.
On commencement, all new staff and HDR students must receive an OHS induction
outlining key safety and emergency information and OHS training available (see 'OHS
induction and training at Monash University)'.
Q17.
Do you check that trades contractors engaged through a BEIMS
request have completed the online Monash Contractor Safety
induction?
Self Audit Questionnaire, v7
Date of first issue: June 2005
Yes
No
The Monash Safety Induction is available on line for use by all units in the induction of
new staff and HDR students. The program aims to provide staff with a brief overview of
OHS policies, procedures and practices at Monash and a basic understanding of their
own OHS responsibilities. New staff and HDR students should complete the program, as
well as being advised of the health and safety aspects of their work, including local OHS
procedures, within the first few days of their arrival.
All Contractors are required to complete the Facilities and Services Contractor Induction
prior to commencing work and register their on-site attendance (signing in) & departure
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 4 of
14/01/2015
Q18.
When trades contractors arrive in your area, you must ensure they
have the Contractor sticker label displayed.
Do all staff complete a local OHS induction that has been
developed in accordance with the OHS Local Induction procedure?
(signing out) at the Facilities and Services kiosk. Contractors are required to wear the
contractor’s registration sticker issued at the kiosk.
Yes
No
Q19.
Do all HDR students complete a local OHS induction that has
been developed in accordance with the OHS Local Induction
procedure?
Yes
No
Q20.
Do all visitors complete a local OHS induction that has been
developed in accordance with the OHS Local Induction procedure?
Yes
No
Q21.
Do all contractors complete a local OHS induction that has been
developed in accordance with the OHS Local Induction procedure?
Yes
No
Q22.
During induction are training needs identified?
Yes
No
And safety issues associated with the work area discussed?
Yes
No
Yes
No
As part of the induction process, new staff members and HDR students must be
provided with a local OHS induction which covers local procedures and information such
as equipment manuals, safety manual(s) and safe work instructions for equipment. As
staff commence their work, they should be instructed in the use of new procedures,
processes and equipment by their supervisor.
Records of OHS inductions and receipt of OHS information must be maintained in the
unit.
OHS training needs must be identified for staff and students working/studying in their
area.
Training
Q23.
Q24.
Do you have a system to identify OHS training requirements for all
staff and students?
Have all staff with safety roles (including managers and supervisors)
and students undertaken all required OHS training in the last 3
years?
Yes
No
The Staff Development Unit coordinates centralised training courses for staff (see 'OHS
induction and training at Monash' and the 'OHS Training Guide'). In addition, the
individual OHS training needs of units can be determined through discussions with local
safety officers, by contacting the Staff Development Unit or OHS Consultant/ Advisor
responsible for your area.
A Training Record form can be used to record local training and is provided at the OH&S
web site.
On a regular basis, OHS training undertaken by staff and students in the unit should be
reviewed against the unit's OHS requirements in order to organise any additional training
required.
Guidance on determining OHS training requirements is provided in the OHS training
guide, available on the OH&S website.
Emergency preparedness
Q25.
Do you have a 333 Emergency procedures booklet by every phone
in your unit?
Yes
No
http://www.monash.edu.au/ohs/topics/emergencies-evacuations.html
(This is not applicable to areas located in hospitals)
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 5 of
14/01/2015
Have evacuation trials been conducted across all the buildings in
which the unit is located as required?
Yes
No
The Monash University OHS Committee requires that either one or two practise
evacuations (depending on building type) are held in Monash University buildings each
year to ensure that all occupants are aware of emergency procedures
Q26.
Has Occupational Health and Safety been informed of evacuations
conducted?
Yes
No
Q27.
Is an up to date contact list of trained first aid staff available in all
relevant public areas?
Yes
No
Q28.
Has a first aid assessment been completed for the unit as required
by the Monash University 'Procedures for first aid'?
Has a copy of the first aid assessment been forwarded to the
Occupational Health Team?
Yes
No
Yes
No
Q30.
Is the assessment less than 3 years old?
Yes
No
Q31.
Does your unit have a defibrillator?
Yes
No
Following each evacuation, a copy of the 'Record of building evacuation form' must be
forwarded to the local OHS committee and to the OHS Consultant/Advisor by the
building warden. The building warden must also keep a copy of the form. Occupational
Health and Safety maintains a record of all evacuations conducted across the University.
Summaries of these figures are reported to the quarterly meetings of the Monash
University OHS Committee in order to monitor performance against targets set each
year.
First aiders must be easy to access. Systems that can be used include displaying lists of
contact details of first aiders or signs to the locations where first aid is available. These
systems must be kept up to date.
The 'Procedures for first aid' require that an assessment is undertaken to determine the
number and competencies of first aiders required and the number and locations of first
aid kits in each area.
A first aid assessment form and accompanying 'Guidelines for assessing the number of
first aiders required' are provided in the procedures. Examples of completed
assessments are provided in the procedures and assistance with the assessment is
available from Occupational Health and Safety, who should be sent a copy of the
completed assessment.
The first aid assessment should be reviewed whenever significant changes occur in the
size/layout of the workplace, the number and/or distribution of employees, the hours of
work or study or the nature of the hazards and the severity of the risks or at least every 3
years.
Section 13.3 'Procedures for first aid'
Defibrillator Maintenance Checklist
Yes
No
Yes
No
All hazards, incidents and accidents involving Monash University staff, students, visitors
and contractors or property must be reported, investigated and corrective/preventive
action recommended. The Monash University 'Procedures for Hazard and Incident
Reporting, Investigation and Recording' set out the actions to be followed.
Yes
No
Workplace safety inspections are planned; systematic appraisals of the workplace which
can help identify and resolve hazards before any harmful event takes place. Inspections
can also assist work areas to comply with OHS legislation.
Q29.
Q32.
Please name the staff member responsible for maintaining the
defibrillator:
Have the required 6 monthly defibrillator checklists been completed
and records kept?
Zoll Defibrillator Checklist
Incident reporting
Q33.
Are all workplace hazards and injuries involving staff, students,
visitors and contractors reported and actioned in a timely manner in
accordance with the Monash University Procedures for Hazard &
Incident reporting, investigation & recording?
Workplace inspections
Q34.
Are two workplace inspections carried out in all of the work areas
occupied by the unit each year?
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 6 of
14/01/2015
Date of last inspection
Q35.
Have workplace inspection findings been forwarded to the OH&S
unit and added to your corrective actions register?
A workplace inspection program is available at the OH&S website. Training in the use of
the workplace inspection program is coordinated centrally by the Staff Development Unit
or the individual OHS training needs of units can be determined through discussions
with local safety officers, by contacting Staff Development or OHS Consultant/ Advisor
responsible for your area
Yes
No
Following each round of inspections, copies of the 'Summary of inspections' form, which
is provided as part of the workplace inspection program, should be completed and
forwarded to the local OHS committee and to Occupational Health and Safety unit.
An OHS risk register is a central repository for all OHS risks identified by the
unit and for each OHS risk includes an OHS risk ranking based on likelihood and
consequence, impact and control strategies (also known as a risk assessment).
Once the acceptable level of risk is achieved, the risk assessments should only be
reviewed when:
• there is a significant change;
• a hazard or incident report is generated; or
• at least every three years.
Risk management
Q36.
Does your unit have a Risk Register?
Yes
No
Q37.
Are all risk assessments reviewed every 3 years?
Yes
No
Q38.
Are risk assessments for laboratories, workshops and studios:
N/A
(i)
(ii)







Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Q39.
based on local procedures
include:
purchase
transport
operations
system of work
maintenance/service/repair/cleaning
waste and decommissioning
working after hours
A Risk Management Program is available to assist with this task.
Training in the use of the Risk Management Program is coordinated centrally or can be
arranged specifically for your work area by contacting the Staff Development Unit. The
Risk Management Program is available to assist with this task
The following documents provide further guidance:




Working After Hours
Off Campus Activities
Office Ergonomics
High risk occupations (VWA)
Are risk assessments for administrative areas:
N/A
(iii) based on local procedures?
(iv) and include:
Yes
No
Training in the use of the Risk Management Program is coordinated centrally or can be
arranged specifically for your work area by contacting the Staff Development Unit. The
Risk Management Program is available to assist with this task





Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
The following documents provide further guidance:
Yes
No
Ergonomics/Manual Handling
Travel to other campuses
Off-campus activities including urban, rural and international
Working After-Hours
Workload (additional resources provided during busy periods
e.g. grant writing, exam periods, end of financial year)
Self Audit Questionnaire, v7
Date of first issue: June 2005
A Risk Management Program is available to assist with this task.




Working After Hours
Off Campus Activities
Office Ergonomics
High risk occupations (VWA)
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 7 of
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
Q40.
Possible encounters with high-risk behaviour by individuals
(e.g. Client-based services, distressed students).
When selecting your risk controls do you use the hierarchy of
controls?
Yes
No
The hierarchy of control ranks risk control measures in decreasing order of desirability
and effectiveness. These are:
• Elimination – Remove the hazard
• Substitution – Exchange the hazard for a lesser one
• Isolation – Separate people from the hazard
• Engineering controls – Use physical barriers to control the hazard
• Administrative controls – Provide information, training and procedures to ensure that
people can manage the hazard appropriately
• Personal Protective Equipment (PPE) – Last layer of defence to stop people from
being exposed to the hazard.
Q41.
Have all relevant staff and students been consulted for each risk
assessment?





supervisor of the area;
personal undertaking the task;
safety officer of the area;
health and safety representative of the area; and
External organisation or subject matter expert (when
appropriate).
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
In accordance with the Victorian OHS Act 2004 s. 35(1), staff must be consulted:
 during risk management;
 when making decisions regarding facilities related to welfare, e.g. toilets, first aid;
 during development of OHS policies and procedures;
 When changes are proposed to the workplace, machinery/equipment, substances,
processes and other things used in the workplace or the work performed that may
affect the health and safety of staff.
Q42.
Have safe work procedures/instructions (e.g. posters and notices,
safe operating procedures, laboratory manuals) been developed
where required?
Yes
No
Safe work instructions provide essential information to ensure staff and students perform
tasks safely. These instructions also assist in the training and orientation of new staff
and students in the hazards of the tasks to be performed, as well as providing them with
the rules and procedures necessary to ensure that they can perform their work in a safe
manner.
'Guidelines for the development of safe work instructions' are available from the OH&S
website, which provide a template and guidance for the content and format of safe work
instructions.
Q43.
Are local procedures in use for staff and students working alone, at
night or weekends?
Yes
No
The 'OHS after-hours procedures' outline a range of strategies for controlling the risks
associated with staff and students who find it necessary to work alone after hours or at
weekends. Local procedures should be developed and communicated to all staff and
students.
Yes
No
A corrective actions register (CAR) is a record of all corrective actions resulting from
audit findings, hazard and incidents, building evacuation reports, workplace inspections
and risk management and risk control review.
Corrective actions
Q44.
Does your unit have a Corrective Actions Register (CAR)?
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 8 of
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Q45.
Does the CAR include corrective actions from the following
sources?








Q46.
Once hazards and issues are identified, corrective actions can be established which
should be preventive in nature.
Responsibility for completing the corrective actions can then be assigned and time frames
for the completion of each action agreed upon and recorded. CAR actions can then be
reviewed and closed out.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
No
Yes
No
OHS Corrective Action Procedure
Yes
No
To ensure the safety of electrical equipment, each academic/administrative unit is
responsible for:
 Ensuring that electrical equipment is inspected, tested and tagged as outlined in
OHS information sheet No. 33: Inspection, testing, tagging & repair of electrical
equipment;
 Withdrawing failed or faulty equipment from service; and

Maintaining records of testing
Yes
No
The Wellbeing@ Monash Champion role contributes to building a healthier Monash
community by promoting and providing input into the Wellbeing at Monash Program. The
role is outlined in http://www.monash.edu.au/ohs/wellbeing/wellbeing-champions.html
Does your unit have a wellbeing program/initiative in place?
Yes
No
Wellbeing programs and services http://www.monash.edu.au/ohs/wellbeing/
Please list (e.g. SWAP, Mindfulness, Healthy Catering):
1.
OHS Internal, external and accreditation audits
OHS Self-audit questionnaire
Hazard and incident investigation
Monitoring and review of OHS Plans
Review of risk management controls
Workplace Inspections
Building evacuations
OHS Committee actions arising
Are all corrective actions closed out within the agreed timeframes?
Electrical safety
Q47.
Has electrical equipment been tested and tagged according to OHS
requirements?
Wellbeing@Monash
Q48.
Is there someone responsible for coordinating wellbeing programs in
your unit?
Name of person responsible:
Q49.
2.
3.
Records & Document Management
Q50.
Are locally created OHS procedures and guidelines controlled in
accordance with Monash University OHS Management system
requirements? And include:


Date Created
Author
Self Audit Questionnaire, v7
Date of first issue: June 2005
Local area OHS documentation is created when the central OHS Management System
policies, procedures and guidelines are not specific enough for the process to be
implemented at the local level.
Yes
Yes
No
No
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 9 of
14/01/2015



Date of next review
Filename/ storage location of document
Reference to the central OHS Management System guidance
document the procedure is based on.
Yes
Yes
Yes
No
No
No
Local OHS documentation should be developed in accordance with Monash University’s
central endorsed policies and procedures to ensure a consistent method of managing
health and safety throughout the organisation.
Regular review of local documents should occur to ensure consistency with the OHS
Management System. All locally produced OHS documentation should be approved by
the local OHS Committee to ensure best practice consultation requirements are met.
OHS Records Management Procedure
Q51.
Are locally created OHS procedures approved and endorsed by the
local OHS committee?
Yes
No
Q52.
Are local records kept in accordance with the OHS Management
System record management requirement?
Yes
No
Yes
No
'Use, design and modification of machinery and equipment at Monash University'
provides guidance to staff, students, visitors and contractors who use
machinery/equipment at Monash University.
B. Machinery or Equipment
Q53.
Does your unit use machinery/equipment (other than personal
computers and office equipment)?
If no, skip to Section C
Q54.
Does your unit have a plant register?
Yes
No
Q55.
Do you have a maintenance schedule for plant?
Yes
No
The OHS Regulations 2007 require that risk management is undertaken on
processes that use machinery and equipment in workshops, laboratories and studios
to identify and assess the risks associated with the machinery/equipment and to
ensure that effective measures to eliminate or reduce the risk of injury are adopted
http://www.monash.edu.au/ohs/topics/machine-equipment-safety.html
Q56.
Are electrical high voltage equipment protected by RCD or lock out
mechanisms?
Yes
No
http://www.monash.edu.au/ohs/topics/procedures/isolation-of-equipment.pdf
Q57.
Is all machinery adequately equipped with guarding and emergency
stop capabilities?
Yes
No
http://www.monash.edu.au/ohs/topics/guard-machine-equipment.html
Q58.
Do certain types of machinery require clearance zones for safe
operation?
Yes
No
http://www.monash.edu.au/ohs/topics/machine-equipment-safety.html
Q59.
Do you supply machinery/equipment to other areas at Monash or
outside Monash?
Yes
No
Q60.
If you supply machinery/equipment to other areas at Monash
or outside Monash, has this been risk managed?
Yes
If machinery/equipment is sold or supplied to other users, the OHS Regulations 2007
require that risk management is completed on the machinery/equipment and that this
information is supplied to the new owner/user. All records associated with the
machinery/equipment must also be provided. 'Use, design and modification of
machinery and equipment at Monash University' provides guidance for the sale or
supply of machinery/equipment.
No
C. Chemicals
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 10 of
14/01/2015
Q61.
Does your unit use chemicals, e.g. for work procedures, cleaning,
teaching, research, preparation of materials?
Yes
No
'Using chemicals at Monash University' provides guidance to staff, students, visitors
and contractors who use chemicals at Monash University.
If no, skip to Section D
Q62.
Do you have a chemical register for:


Laboratories
And external storage areas
Yes
Yes
No
No
'Using chemicals at Monash University' (Section 10.1.1) All areas must maintain a
chemical register, which includes:

A list of all chemicals currently in use, and

Either a hard copy or access to an electronic copy of the Material Safety
Data Sheet (MSDS) for each chemical
Q63.
Are local procedures in place for unattended chemical reactions?
Yes
No
The risks associated with unattended reactions must be assessed using the Monash
University Risk Management Program and strategies developed to reduce or
eliminate identified risks. This includes testing of systems before use, implementation
of fail safe systems, signage and notification to Security staff.
Q64.
Q65.
Does your unit use any scheduled carcinogens?
Is there a procedure for storage and handling of scheduled
carcinogens?
Yes
Yes
No
No
Specific requirements for the use of scheduled carcinogen substances are included in
the OHS Regulations 2007. To ensure that units comply with these requirements,
they are asked to notify Occupational Health and Safety of any use of a scheduled
carcinogen, a list of which is provided by the Victorian WorkCover Authority.
Q66.
Do you supply chemical substances to other areas at Monash or
outside Monash?
Do you supply a MSDS for the chemical substances you supply?
Are chemicals stored according to Monash University storage limits
for dangerous goods?
Do you have a process for labelling stored (including fridges and
freezers) and decanted chemicals?
Yes
No
It is a legislative requirement for the manufacturer or importer to supply a copy of the
MSDS for each chemical to the end user.
Yes
Yes
No
No
Yes
No
All containers of chemicals or chemical waste must be labelled clearly. The General
chemical storage guidelines available at the OH&S web site and in poster form
provide an overview of storage of all chemicals in laboratory/studio/workshop areas
www.monash.edu.au/ohs/topics/chemical-safety.html.
Q70.
Are the dangerous goods storage cabinets functioning according to
the manufacturing standards?
Yes
No
Q71.
Is there a procedure for managing chemical waste?
Yes
No
The OHS Regulations 2007 and Dangerous Goods (Storage & Handling)
Regulations 2000 require that risk management is undertaken for the use, storage
and handling of chemicals to identify and assess the risks associated with the
chemicals and to ensure that effective measures to eliminate or reduce the risk of
injury are adopted.
Chemical Waste Disposal
Q72.
Do you have a procedure for purchasing, handling and storage of
scheduled poisons?
Yes
No
Purchase and Storage of Scheduled Poisons
Q73.
Are your fume cupboards tested annually?
Yes
No
Q74.
Is there a process for the use of fume hoods?
Yes
No
The Australian Standard AS/NZS 2243.8 - 2006 Safety in Laboratories - Fume
Cupboards requires fume cupboards to have their performance tested on a regular
basis. Testing of the face velocity together with smoke testing should occur on an
annual basis.
Use of local exhaust ventilation systems: fume cupboards
Q67.
Q68.
Q69.
Self Audit Questionnaire, v7
Date of first issue: June 2005
http://www.monash.edu.au/ohs/topics/dangerous-goods-storage.pdf
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 11 of
14/01/2015
Q75.
Q76.
Do you have procedures for the management of spills?
Is there a process for regular testing of safety showers?
Yes
Yes
No
No
http://www.monash.edu.au/ohs/forms/spill-kits-laboratories.pdf
All safety showers and eyewash facilities must be regularly flushed and checked to
ensure they are fully functional.
This function is centrally managed by Facilities and Services
Phone: 9902 0222
Email: facilities.services.clayton@monash.edu
D. Gas cylinders
Q77.
Does your unit use gas cylinders?
Yes
No
Yes
No
Yes
No
Yes
No
If no, skip to Section D
Q78.
Are all gas cylinders controlled by your unit 'in use'?
Q79.
Is there a procedure for the storage and handling of gas cylinders?
Q80.
Are gas cylinders stored according to Monash University
guidelines?
‘In Use’ refers to a pressurised gas cylinder currently in use. E.g. An in use cylinder
may include one that is fitted with a regulator and connected to associated equipment.
All gas cylinders in the University must be properly restrained, whether in use, being
stored or being transported - this includes "empty" cylinders. Cylinders being stored or
in use will be secured to a fixed structure. Where possible, cylinders be stored in, and
used from secure locations outside of buildings. Refer to Australian Standard 43321995 The storage and handling of gases in cylinders and Australian Standard 2243.101993 Safety in Laboratories Part 10: Storage of chemicals for more detailed guidance
on safe storage of gas cylinders used in laboratories.
E. Lasers
Q81.
Does your unit use lasers that are class 3R, 3B or 4?
Yes
No
Laser safety - OHS information sheet
Yes
No
A laser safety officer is required for all class 3B and 4 lasers and class 3R laser that
emit in the non-visible spectrum.
If no to the question above, skip to Section F
Q82.
Has your unit appointed a laser safety officer?
Please name:
Q83.
Does your unit have an established system for local training on your
class 3R, 3B or 4 lasers?
Yes
No
All users of class 3R, 3B or 4 lasers must undergo training in their safe operation and
correct use of laser safe eyewear.
Q84.
Does your unit have an established system for authorisation of users
of class 3R, 3B or 4 lasers?
Yes
No
A system for authorisation of users is recommended for user of class 3R, 3B and 4
lasers.
Q85.
Does your unit have a system to control access to 3B or 4 class
lasers? (door interlocks, emission indicators)
Yes
No
Interlocks are required for class 3B and 4 systems. Emission indicators are required
for all class 3B and 4 lasers and class 3R laser that emit in the non-visible spectrum.
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 12 of
14/01/2015
Q86.
Does your unit require laser eye exams for students and staff that
work with 3B or 4 class lasers?
Yes
No
Laser eye examinations are recommended for user of class 3B and 4 lasers.
'Using ionising radiation at Monash University’ provides guidance to staff, students,
visitors and contractors who use ionising radiation at Monash University.
F. Radiation
Q87.
Does your unit have or use unsealed sources?
Yes
No
Q88.
Does your unit have or use sealed sources?
Yes
No
Q89.
Does your unit have or use X-ray units?
Yes
No
If no to all of the Qs above, skip to Section G
Q90.
Have you notified Occupational Health and Safety of all radioactive
sources in use?
Yes
No
Q91.
Has your unit appointed a radiation safety officer (RSO)?
Yes
No
Yes
No
For radiation safety officers (RSO) - Monash University
All sealed sources, sealed source apparatus and X-ray units must be registered with
the Department of Human Services via Occupational Health and Safety. When
purchasing these items, the RSO of the area should contact the RPO for assistance
with the registration process.
Ionising Radiation: Source Purchase and Licensing Procedures
Please name.
Q92.
Has your unit appointed a deputy radiation safety officer?
The University Radiation Protection Officer at Occupational Health and Safety is
responsible for facilitating the University’s compliance with the Radiation Act 2005,
assisted by Radiation Safety Officers in each area where radiation is used. The
Radiation Protection Officer can be contacted at Occupational Health and Safety on Ext.
51016 or via ohshelpline@monash.edu.
Areas that use radioactive substances, sources and/or apparatus must appoint a
radiation safety officer (RSO) and a deputy radiation safety officer (if required) to
assist staff and students with radiation matters.
Please name.
Q93.
Are radioactive sources and apparatus registered as required under
the Radiation Act 2005?
Yes
No
Q94.
Does your unit have a purchasing procedure for radioactive
substances, sources and apparatus to ensure the appropriate
licenses are in place before purchasing?
Yes
No
Q95.
Does your unit have a system to monitor staff and student exposure
to ionising radiation (e.g. personal radiation monitoring badges)?
Yes
No
‘Ionising radiation dosimetry procedures’ provides information and guidance on these
requirements.
Q96.
Does your unit have a system to control access to radioactive
sources and X-ray units, e.g. locked cupboards or laboratory, log
books, etc.?
Yes
No
Q97.
Does your unit have established procedures for the disposal of
radioactive waste that it generates?
Yes
No
Access to radioactive sources and X-ray units must be limited to those provided with
information and training in their use. Appropriate access control methods include
locking laboratories, locking cupboards, signage and/or the use of log books to
ensure that only authorised radiation users are accessing equipment.
Disposal of Radioative Waste Procedure
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 13 of
14/01/2015
G. Biologicals
Does your unit use biological substances, e.g. human blood, bodily
fluids or tissues, microorganisms, animal blood or tissues, cultured
cells, biological products derived from cells, microorganisms or
animals?
Yes
No
'Using biologicals and animals at Monash University' provides guidance to staff,
students, visitors and contractors who use biologicals and animals at Monash
University.
If no, skip to Section H
Q98.
Has your unit appointed a biosafety officer?
Yes
No
Areas that use biological substances must appoint a biosafety officer.
Q99.
Q100.
Please name:
Please provide the date of your latest OGTR Audit.
Have all corrective actions from this audit been implemented?
Yes
No
OHS Corrective Action Procedure
Q101.
Have immunisation requirements been identified?
Yes
No
Procedures for Immunisation
Work Related Immunisation Requirements for Monash University Staff and Students
H. Animals
Q102.
Do staff in your unit use or have contact with animals during their
work, teaching or research?
Yes
No
'Using biologicals and animals at Monash University' provides guidance to staff,
students, visitors and contractors who use biologicals and animals at Monash
University.
Fit testing is required to be conducted for all staff/students that are required to wear
respiratory protection in line with AS/NZS 1715:2009 Selection, use and
maintenance of respiratory equipment.
If no, you have completed this review.
Q103.
If your work requires you to wear a mask, have you been 'fit tested'
(for an appropriate mask)?
Yes
No
Q104.
Have the appropriate health surveillance measures been identified?
(e.g. lung function testing)
Have immunisation requirements been identified?
Yes
No
Yes
No
Q105.
Health Surveillance Procedure
Procedures for Immunisation
Work Related Immunisation Requirements for Monash University Staff and Students
You have now completed this audit.
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 14 of
14/01/2015