Monash University Occupational Health & Safety Committee (MUOHSC)
Meeting:
Date:
Venue:
1/2015
Thursday, 26th February at 1.00pm
Facilities & Services Division Board Room 1, G04, 30 Research Way, Clayton Campus
Meetings of the Monash University Occupational Health and Safety Committee are attended by
Management Representatives, Employee Representatives and Observers.
Apologies to be emailed to Lynne.Peterson@monash.edu
Lynne Peterson
Minute Secretary
February 2015
AGENDA
1.
PROCEDURAL MATTERS
1.1
APOLOGIES
1.2
ATTENDANCE
1.3
MINUTES OF PREVIOUS MEETING
The Committee is asked to confirm the minutes of meeting 4/2014 held on
rd
Wednesday, 3 December 2014.
The Chairperson
1.4
MEMBERSHIP
1.4.1
Resignation
The Chair to acknowledge the resignation of the following members:
•
•
•
Doug McGregor, Management Representative from the Faculty of Medicine,
Nursing & Health Sciences
Dan Wollmering, Employee Representative from the Caulfield Campus
Tim Wong, Employee Representative from the Berwick Campus
1.4.2
Appointment
The Chair to welcome the following committee member:
•
Jill Fitzroy (Faculty General Manager), Management Representative from the
Faculty of Medicine, Nursing and Health Sciences
For Discussion – The Chairperson
1.5
2.
URGENT BUSINESS AND STARRING OF ITEMS
MATTERS ARISING FROM PREVIOUS MINUTES
2.1
MONASH UNIVERSITY OCCUPATIONAL HEALTH & SAFETY PLAN
(MINUTES - ITEM 2.1)
The Executive Secretary to update members in regard to the progress of an online
system enabling staff to submit their quarterly OHS Plan updates online.
The Executive Secretary
Agenda 1-2015
AUTHOR: MANAGER, OH&S
PAGE 1 OF 4
09/02/15
2.2
REPORTS FROM SUB-COMMITTEES (MINUTES - ITEM 3.1)
At the last meeting, Margaret Rendell, the University’s Radiation Protection Officer,
asked whether the Chairperson of this committee could write to the Dean of
Medicine requesting that they nominate a suitable staff member to fill the vacant
position of Chair of the Radiation Advisory Committee. The Executive Secretary to
update members.
The Executive Secretary
2.3
HAZARDOUS MATERIALS (MINUTES - ITEM 4.2)
Andrew Picouleau to update members on whether Finance has moved towards
enforcing more stringent guidelines when purchasing of hazardous chemicals at
Monash University.
Andrew Picouleau
2.4
GENERIC FACULTY/DIVISION OH&S PLAN 2015 (MINUTES – ITEM 4.3)
The Chair to speak to this item.
The Chairperson
2.5
MONASH UNIVERSITY OHS COMMITTEE STRUCTURE (MINUTES - ITEM 4.4)
The Executive Secretary to speak to this item.
The Executive Secretary
3.
REGULAR BUSINESS
3.1
REPORTS FROM SUB-COMMITTEES
3.1.1
Fire Risk Management Committee
A report on the activities of the Fire Risk Management Committee for 2014 is
attached. Bradley Williamson, Acting Director, Facilities & Services Division to
speak to the report.
1/2015
Summary
Bradley Williamson
3.1.2
Wellbeing Sub-Committee
Approval was given at the last MUOHSC meeting for the establishment of the
Health and Wellbeing Sub-Committee. Invitations for membership have been sent
and the sub-committee is awaiting final confirmation.
For Noting
3.2
MONASH UNIVERSITY OHS PROGRESS REPORT
The Monash University OHS Progress Report is attached:
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.2.6
3.2.7
3.2.8
3.2.9
2/2015
Incidents & Hazards
Workers’ Compensation
Unacceptable Behaviour
WorkSafe Reports Summary
Building Evacuations
Audits
Induction
OHS Training
Wellbeing
For Noting
Agenda 1-2015
AUTHOR: MANAGER, OH&S
PAGE 2 OF 4
09/02/15
3.3
OHS DOCUMENTATION FOR ENDORSEMENT AND INFORMATION
Documents for approval will not be presented at this meeting.
For Noting
3.4
AUDITS
3.4.1
Audits for Q4 2014 were conducted for the following areas:
3.4.1.1 Internal Audits
•
Research Office - OHS Management System Audit
•
Australian Regenerative Medicine Institute (ARMI) - Chemical
Procedural Audit.
3.4.1.2
External Audits
A specialist radiation audit was commissioned to review all the OHSMS
procedures and compared requirements in the OHS Legislation,
subordinate legislation's and Australian Standards. An audit to assess the
level of implementation was conducted in each of the following areas.
•
•
•
3.4.2
Department of Biochemistry
Department of Physiology
School of Chemistry
Self-Audit Questionnaire
3/2015
The self-audit questionnaire was reviewed and updated in Q4 2014. Many
changes have been made to this tool which is attached for
your reference.
For Noting
3.5
SMOKE-FREE UNIVERSITY
Paul Barton to update members on the smoke-free initiative at Monash University.
Paul Barton
4.
NEW BUSINESS
4.1
INFLUENZA IMMUNIZATIONS
The Executive Secretary to speak to this item.
The Executive Secretary
4.2
OHS INDUCTION FOR MANAGERS & SUPERVISORS
John Hayman, OHS Consultant to present on the above item.
John Hayman
5.
NEXT MEETING
Date:
Time:
Venue:
Agenda 1-2015
th
Thursday, 28 May 2015
10.00am
Facilities & Services Division Board Room 1, G04, 30 Research Way, Clayton Campus
AUTHOR: MANAGER, OH&S
PAGE 3 OF 4
09/02/15
MEMBERSHIP:
Faculty Representatives
Faculty
Management
Representatives
Art, Design & Architecture
Arts
Business & Economics
Martin Taylor
Margaret Murphy/
Louise Francis
John Loughran
Education
Employee
Representatives
(Health & Safety
Representatives)
Stuart Lees
Jill Crisfield
Jill Fitzroy
Caulfield
Clayton
Caulfield
Clayton
(Chairperson, Nominee
of the VC)
Engineering / Information Technology
Law
Medicine, Nursing & Health Sciences
Pharmacy & Pharmaceutical Sciences
Science
Campus
Diane O’Neill
Lisa Kaminskas
Nino Benci
Clayton
Clayton
Clayton
Parkville
Clayton
Divisional Representatives
Division
Management
(includes Campus Community Division, eSolutions,
Marketing & Student Recruitment and associated
direct reports)
Stephen Davey
Andrew Picouleau
(includes Corporate Finance)
Office of the Provost & Senior VP
Libraries
Risk and Compliance
Campus
TBA
TBA
TBA
Clayton
Clayton
TBA
(Health & Safety
Representatives)
Office of the Chief Operating Officer & Senior VP
Facilities & Services Division
Monash HR
Chief Financial Officer & Senior VP
Employee
Representatives
Moh-Lee Ng
TBA
Michael Barry
TBA
Peninsula
Clayton
In Attendance
Executive Secretary
Norman Kuttner
NTEU Representative
Stan Rosenthal
Facilities & Services
Paul Barton
Occupational Health & Safety
John Tsiros
Monash Postgraduate Association (MPA)
Vacant
Monash Student Association (MSA)
Vacant
Minute Secretary
Lynne Peterson
Agenda 1-2015
AUTHOR: MANAGER, OH&S
PAGE 4 OF 4
09/02/15
MUOHSC 1/2015
Facilities & Services Division - Fire Risk Management Committee Background
The Fire Risk Management Committee of the Facilities & Services Division (FSD) utilises a strategic
risk management approach in assessing the fire risk of buildings on each Australian Monash
University campus.
Each campus building is required to be maintained to the relevant standards and codes at the time
they were built. The Division provides ongoing monitoring to ensure the fire protection systems of
campus buildings are maintained to the applicable standards and codes relevant to the building whilst
seeking to upgrade systems to reduce the overall fire risk of the university’s buildings. The priority of
the committee is life safety.
The Committee performs ongoing monitoring and review of potential fire risk issues. In addition, the
Committee provides guidance, prioritisation and allocation of fire risk funding and spending through
the application of a Fire Risk Management Tool.
Fire Risk Management Tool
The Fire Risk Matrix Tool has been developed for use within the Division and is designed to inform
the fire risk categorisation of campus buildings. The listing is intended to guide the prioritisation of
funding, planning and works as it incorporates a range of different rating factors to the specifics of
each university building.
The Fire Risk Matrix is designed to be a general guidance tool, and is not to be used as a substitute
for detailed fire risk engineering assessment
A number of categories are used to determine the fire risk rating of a building including:
Number of levels
Use of building (room type)
Space quality of building
Condition of building and fire protection systems
Group of 8 benchmarking
Details contained in the Fire Risk Matrix are obtained from the Campus Summary Report provided by
the Space Management Unit, and annual TEFMA reporting.
The matrix is updated every 3-4 months as building details are subject to ongoing review and change.
Fire Risk Management Committee - Composition
The Fire Risk Management Committee meets on a quarterly basis to review the monitoring and
management of potential fire risks.
The Committee membership is as follows:
Stephen Davey
Paul Barton
Brendon Robinson
Wayne Brundell
Aldo Gangi
Mike Scott
John Tsiros
David Williams
Fire Risk Management Executive Director, Facilities & Services Division (Chairperson)
Director, Business Support
Director, Projects
Director, Services
Manager, Asset Planning & Development
Manager, Strategic Planning & Information
Principal Occupational Health & Safety (OHS) Consultant
Risk & Compliance Officer (Secretary)
February 2015 OHS Committee Update Facilities & Services Division - Fire Risk Management Committee Agenda items for the Committee include, but are not limited to:
Statistics on Fire Alarms
The Maintenance & Minor Works area provides the Committee with details of fire alarms for all
Monash University Australian campuses. Details provided include alarms triggered by actual fire,
contractor fault, faulty detector, faulty equipment, food preparation, occupant fault, student fault
and other / unknown faults. In addition, the statistics also highlights details of malicious /
deliberate incidents.
These statistics enable the Committee to monitor buildings with high frequencies of evacuations due
to false alarms and prioritise mitigating works where applicable.
Fire Start Incidents
The OHS unit presents details of reported actual and potential fire start incidents to the Committee.
The reporting includes hazard and report type classifications that indicate which incidents were
actual fires or fire risk situations (e.g.: hazard, near miss)
Building Evacuation Statistics
The Committee is provided with details of statistics relating to building evacuations by the OHS unit.
The OHS consultants and advisors actively stress the importance of compliance with the Monash
building evacuation requirements and the need to conduct the required number of building
evacuations.
The OHS unit provides support to building wardens in undertaking trial evacuations in a timely
manner.
Essential Services Maintenance
Details of Essential Services Maintenance are provided to the Committee through the Verified
system, which manages and monitors essential services maintenance and provides a proactive
view of the status of each building. Data obtained from Verified is presented to Maintenance &
Minor Works meetings on a monthly basis for monitoring and action, where required.
Sign-off of Essential Services Maintenance is completed for each campus in September on an
annual basis.
Emergency & Evacuation Diagrams
The Strategic Planning area is responsible for the review, preparation, drawing and distribution of
emergency and evacuation plans in each of the buildings on all campuses.
An additional resource has been sourced to manage the currency of building emergency and
evacuation diagrams.
The Committee is currently monitoring the progress of updating of emergency and evacuation
diagrams, and providing guidance and decision-making when required.
Fire Risk Management February 2015 OHS Committee Update Facilities & Services Division - Fire Risk Management Committee Current Project Plans Incorporating Major Fire System Upgrades
Review of current list of projects and fire risk assessments. Details of projects in design and
construction are reviewed by the Planning area, primarily for details relating to electrical and fire
systems. Comments from the Planning area are incorporated in the design list to ensure fire
emergency systems are included. Both the Projects and Planning areas review current projects to
ensure the scope of fire improvements are sensitive to the building solution.
Halls of Residences
All works associated with existing Halls of Residences in the Clayton campus have been completed
with sprinkler systems installed and commissioned. Fire Protection Services Specifications have
been incorporated in all stages of the new residential project, with updates provided to each meeting
of the Committee.
Fire Risk Management February 2015 OHS Committee Update Fire Risk Management Committee Activities - 2014

Monitoring of false alarms, particularly within the Campus Centre - ongoing
monitoring by the Committee of fire detection upgrades within the Campus
Centre, and all other buildings where there is an obvious increase in statistics.
This has led to occupant education in relation to false alarms being conducted
at tenancy meetings.
At each meeting the Committee reviews the top 5 buildings for fire alarm
statistics both for the University and Clayton campus. Works undertaken in
the Campus Centre during the second half of 2014 has resulted in a
significant decrease of reported alarms.

Review of fire start incidents – where required, the Committee has
prioritised work in identified buildings to minimise threats to life safety

Ongoing reporting of trial building evacuations – Type A buildings (where
Monash is the sole occupier) require trial evacuations twice per year and Type
B buildings (where Monash shares accommodation with outside companies)
require trial evacuations once per year.

Fire Risk Assessment Tool – the Committee reviews the fire risk
assessment tool at each quarterly meeting to review the fire risk
categorisation of campus buildings. The listing guides the prioritisation of
funding, planning and works as it incorporates a range of different rating
factors to the specifics of each university building.

Current project plans – at each meeting, the Committee has reviewed
details of projects in design and construction to ensure fire emergency
systems are included and provide prioritisation where requested and required.

Essential Services Maintenance – ongoing reporting is provided to the
Committee for the annual September sign-off of Essential Services
maintenance. Updates are provided on the progress of upgrades and
installations of fire protection systems.
Fire Risk Management Committee Activities - 2014

Fire Risk Compliance – the Committee regularly review compliance with fire
regulations and standards to ensure all works are completed in a timely
manner.

Emergency and Evacuation Plans - the Committee has monitored the
status of preparation and posting of emergency and evacuation plans for each
of the buildings on all campuses. The Committee has ensured additional
funding has been made available for additional resources to be assigned to
ensure the completion of the update of plans.
In addition, the Committee has reviewed the progress of updating and
distribution of the Emergency Procedures Booklet (completed February 2015)

Review of compliance assessments – the Committee has reviewed
compliance assessments conducted by an external consultant for high fire risk
buildings previously identified as requiring a fire risk review. The Committee
has prioritised fire safety aspects and the program of works for each of the
buildings. This has led to priority being set in relation to other major planned
works.

Budget requirements – the Committee has reviewed the buildings assessed
by the external consultant to ensure they are part of the Capital Development
Plan, and that budgets are reviewed to assess priorities.

Stage 1 RESI Project – the Committee reviews updates provided by the
Projects area in relation to Fire Protection Services Specifications for the
residential project currently underway. The Committee has received
assurance that the specification has been reviewed and endorsed by the FSD
Planners as part of the design review / stakeholder engagement.
In addition, the Committee is provided with a summary Fire Engineering and
BCA Report by the Director Projects at each meeting
MUOHSC 2/2015
Monash University OHS Progress Report
Quarter 4, 2014
Table of Contents Incidents and Hazards .................................................................................................... 2 Unacceptable Behaviour................................................................................................. 6 WorkSafe Reports Summary .......................................................................................... 7 Audits .............................................................................................................................. 8 Building Evacuations .................................................................................................... 10 Induction ....................................................................................................................... 11 OHS Training ................................................................................................................ 12 Wellbeing ...................................................................................................................... 13 MUOHSC Progress Report – Qtr 4/2014
AUTHOR: MANAGER, OH&S
Page 1 of 13
19/02/2015 Incidents and Hazards
This section includes data about all hazard and incident reports (hazards, incidents and near-misses)
submitted to OH&S.

Incident: Any occurrence that leads to, or might have led to, injury or illness to people, danger
to health and/or damage to property or the environment. For the purpose of this report, the term
'incident' is used as an inclusive term for injuries/illnesses, accidents and near misses.
Injury/Illness: Any physical or emotional wound, damage or impairment resulting from an event
in the work environment.
Near-Miss: Any occurrence that might have led to injury or illness to a person.
Hazard: Any set of circumstances that have the potential to cause injury or illness to a person.



Encouraging an increase in reporting of hazards generally allows for appropriate controls to be
implemented, leading to a potential related decrease in the number of reported incidents.
Total Reports Received by Category
Injury Illness
Near Miss
Hazard
Unacceptable Behaviour
180
160
Number of Incident
140
120
100
80
60
40
20
2010
2011
2012
2013
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
0
2014
This illustrates the normal fluctuations experienced in previous years. It is anticipated that all reports
will increase with the introduction of the online hazard and incident reporting system.
MUOHSC Progress Report – Qtr 4/2014
AUTHOR: MANAGER, OH&S
Page 2 of 13
19/02/2015 Ratio of Total Reports to FTE
Rolling Year (Qtr. 1, 2014 ‐ Qtr. 4, 2014)
Injury Illness per FTE
Near Miss per FTE
0
200
400
Hazard per FTE
600
800 1000 1200 1400 1600 1800
1,577
Vice‐Chancellor and President
118
Vice‐President (Services)
348
Faculty of Science
447
Faculty of Pharmacy and Pharmaceutical Sciences
260
Faculty of Education
218
Chief Information Officer and Vice‐President (Information)
688
Provost and Senior Vice‐President
532
Faculty of Arts
390
Faculty of Law
110
Faculty of Engineering
362
Faculty of Information Technology
140
Chief Operating Officer and Senior Vice‐President
171
Faculty of Art Design and Architecture
88
Faculty of Business and Economics
502
Chief Financial Officer and Senior Vice‐President
209
Vice‐President (Marketing Communications and Student
Recruitment)
133
0.00
0.05
0.10
0.15
0.20
0.25
Total Full Time Equivalent (FTE) Staff per area
Faculty of Medicine Nursing and Health Sciences
0.30
Ratio of Incidents to FTE
The ratio of total reports compared with FTE approximates the level of risk of each area by comparing
the number of hazards, near misses and incidents reported with a rolling year against the size of the
area. Higher bars indicate higher risk. A higher ratio of near misses and hazards compared to near
misses indicates a strong safety culture. This does not account for under reporting.
MUOHSC Progress Report – Qtr 4/2014
AUTHOR: MANAGER, OH&S
Page 3 of 13
19/02/2015 2010
MUOHSC Progress Report – Qtr 4/2014
2011
2012
AUTHOR: MANAGER, OH&S
2013
2014
Quarter 4
Quarter 3
2013
Quarter 2
Quarter 1
Quarter 4
Quarter 3
2012
Quarter 2
Quarter 1
Near Miss
Quarter 4
Quarter 3
2011
Quarter 2
Quarter 1
Quarter 4
Quarter 3
2010
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Number of Near Misses
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Number of Injuires / Illnesses
Injury / Illness Reported
180
160
140
120
100
80
60
40
20
0
2014
Hazards and Near Misses Reported
Hazard
160
140
120
100
80
60
40
20
0
As from Qtr. 2, 2013, Near Misses have been identified as a distinct category in hazard and incident
reporting.
Page 4 of 13
19/02/2015 Workers’ Compensation
In the event that a staff member suffers an injury or illness, and it is established and accepted as a
work-related injury, the University compensates the staff member for any time loss, and medical
expenses (up to the current employer threshold amount) incurred as a result of the injury or illness.
Workers' Compensation Claims 14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Qtr1
Qtr2
Qtr3
Qtr4
Qtr1
Qtr2
2012
Qtr3
Qtr4
Qtr1
2013
Qtr2
Qtr3
Qtr4
2014
Number of claims
2012 2013
26 Accepted
25 2014
30
The chart below shows the types of injuries sustained by staff while conducting activities for Monash
University. For more information please visit: http://www.adm.monash.edu.au/workplace-policy/staffwellbeing/employee-assistance/
Types of Injuries Compensated since 2012
Other (Skin Reaction); 1; 1%
Other (Chemical Exposure); 1; 1%
Concussion; 1; 1%
Stress
; 5; 6%
Laceration; 6; 8%
Fracture; 8; 10%
Strain/Sprain; 47; 58%
Contusion; 12; 15%
MUOHSC Progress Report – Qtr 4/2014
AUTHOR: MANAGER, OH&S
Page 5 of 13
19/02/2015 Unacceptable Behaviour
Unacceptable Behaviour is that behaviour that has created or has the potential to create a risk to the
staff member’s health and safety. Examples of unacceptable behaviour include but are not limited to:







bullying
emotional, psychological or physical violence or abuse
occupational violence
coercion, harassment and/or discrimination
aggressive/abusive behaviour
unreasonable demands and undue persistence; and
disruptive behaviour
Definition of categories:
Hazard – a hazard is the reporting of an issue where no injury has occurred
Injury – an injury is where someone seeks medical treatment or takes time off work
Unacceptable Behaviour Reports Received
Hazard
Injury
9
8
Number of reports received
7
6
5
4
3
2
1
0
Qtr1
Qtr2
Qtr3
Qtr4
Qtr1
Qtr2
2012
MUOHSC Progress Report – Qtr 4/2014
Qtr3
2013
AUTHOR: MANAGER, OH&S
Qtr4
Qtr1
Qtr2
Qtr3
Qtr4
2014
Page 6 of 13
19/02/2015 WorkSafe Reports Summary
WorkSafe will investigate situations where significant hazards have been identified or incidents have
occurred at Monash University. All visits result in an Entry Report. All Notices must be rectified by
the identified compliance date.
Date
Type of report
20/10/2014 Entry Report Reference No.
Area
V01021701183L School of Chemistry Issue
Status/Action
Required
Complaint received of lack ventilation for Dangerous Goods in storage cabinets, strong odours emanating from dangerous goods. WorkSafe sighted appropriate documentatio
n and were satisfied that most of the flammable liquid storage cabinets were vented and that the dangerous goods were property segregated. No further action is required. MUOHSC Progress Report – Qtr 4/2014
AUTHOR: MANAGER, OH&S
Page 7 of 13
19/02/2015 Audits
The Monash University audit system is built
around OHS AS18001, which requires
review of the implementation of the OHS
Management System. The audit program is
delivered by OH&S and includes audits run
by external agencies and OH&S. Audits are
conducted at Monash University to ensure
legislative compliance and provide
independent feedback on the level of safety
systems that are currently in place.
Not Scheduled N/A
Green
Yellow
Red
Audits not conducted during this year
Percentage of compliance not required within scope of audit >75% compliance or Compliant (C)
50% ‐ 75% compliance or Major Opportunity for Improvement (OFI) <50% compliance or Non‐Complaint (NC)
2013
Status
Number of Audits run
2014
Average of Percentage
Number of
Average of Percentage of
of Compliance
Audits run
Compliance
Completed
Academy of Performing Arts Operations
1
59%
Architecture
1
N/A
Campus Community Division
2
N/A
Caulfield Sch of Info Technology
1
N/A
Central Clinical Sch
Eastern Health Clinical Sch
1
88%
1
N/A
4
N/A
1
89%
1
95%
1
N/A
90%
Facilities & Services Division
7
77%
Faculty of Education
1
100%
Faculty of Law
Fine Arts
1
73%
George Jenkins Theatre
1
N/A
Indigenous Engagement Unit
1
76%
Mechanical & Aerospace Engineering
2
N/A
Monash HR
Monash University Library
2
2
82%
Sch of Biological Sciences
1
N/A
Sch of Geography & Environ Science
1
92%
Sch of Geosciences
1
99%
Sch of Primary Health Care
1
N/A
Procure to Payment Services
School of Clinical Sciences at Monash Health
1
N/A
School of Primary Health Care
1
85%
Vice-Provost (Res & Res Infrastructure)
2
N/A
Report not completed
Department of Accounting
1
Scheduled
Aust Regenerative Medicine Institute
1
Office of the VC & President
1
Sch of Biomedical Sciences
2
Sch of Chemistry
1
Vice-Provost (Research)
1
Total
25
81%
21
89%
Not Scheduled in 2013/2014
CIO & Vice-President (Information)
Faculty of Pharmacy & Pharmaceutical Sci
VP (Mkting Comms & Student Recruitment)
MUOHSC Progress Report – Qtr 4/2014
AUTHOR: MANAGER, OH&S
Page 8 of 13
19/02/2015 Total Number of Audits completed by Type of Audit
20
Certification
15
External
Internal
Surveillance
10
5
0
2012
MUOHSC Progress Report – Qtr 4/2014
2013
AUTHOR: MANAGER, OH&S
2014
Page 9 of 13
19/02/2015 Building Evacuations
Building evacuations are required to ensure that stakeholders within the building are aware and able to
respond to those emergencies in the safest and timeliest way possible. For buildings controlled by Monash
(Category A), an evacuation is required each semester. For those buildings not under Monash control or
otherwise identified (Category B), 1 evacuation per year is required. All false alarms and genuine
emergencies which result in an evacuation are included.
2 evacuations required per year (category A buildings) Semester 2 Semester 1 Semester 2 Semester 1 2014 Semester 2 2013 Semester 1 2012 Semester 2 2011 Semester 1 Campus Berwick 64% 64% 64% 64% 100% 100%
100% 100% Caulfield 85% 38% 92%
62%
100%
100%
100% 100% Clayton 49% 60% 81% 75% 98% 100%
100% 100% Notting Hill 100% 100% 100%
0%
100%
100%
100% 100% Parkville 100% 100% 100% 100% 100% 100%
100% 100% Peninsula 47% 63% 74%
53%
100%
100%
100% 100% Total 60% 60% 80% 71% 99% 100% 100% 100% 1 evacuation required per year (category B buildings) Campus Alfred 2011 50% 2012
50% 2013
100%
2014
100%
100% 100%
100%
100%
Clayton 30% 60% 100%
100%
Gippsland 67% 100% 100%
100%
Mildura 0% 0% 100%
100%
Misc. 100% 100% 100%
100%
Peninsula 0% 0% 100%
100%
Sale ‐ SRM 100% 0% 100%
100%
Traralgon ‐ Latrobe Regional Hospital Total 100% 0% 100%
100%
48% 57% 100% 100%
Boxhill MUOHSC Progress Report – Qtr 4/2014
AUTHOR: MANAGER, OH&S
Page 10 of 13
19/02/2015 Induction
The online OHS induction is required to be completed within 4 weeks of starting at Monash University
and are tracked via SAP.
Induction of “New Starters” ‐ year to date performance Adjunct, Casual, Sessional, External
Fixed Term & Tenured
Inducted After 4 Weeks
18%
Not Inducted
22%
Inducted Within 4 Weeks
60%
Inducted After 4 Weeks
7%
Not Inducted
82%
Total Inducted: 78% Inducted Within 4 Weeks
11%
Total Inducted: 18% Induction of all Fixed Term and Tenured staff per quarter Percentage currently inducted
Percentage lapsed induction
Percentage not inducted
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Qrt 1 Qrt 2 Qrt 3 Qrt 4 Qrt 1 Qtr 2 Qrt 3 Qrt 4 Qrt 1 Qtr 2 Qrt 3 Qrt 4 Qrt 1 Qtr 2 Qrt 3 Qrt 4
2011
2012
2013
2014
MUOHSC Progress Report – Qtr 4/2014
AUTHOR: MANAGER, OH&S
Page 11 of 13
19/02/2015 OHS Training
OHS training is critical to ensuring that staff and students have been provided with the most up to
date safety information relevant to their activities. Training is provided both at the local level and
across the university as facilitated by the Staff Development Unit. Monash University OHS training is
tracked via SAP.
NOTE
 Training attendance may fluctuate yearly due to the 3 year timeframe required for refresher training
for staff
 Gas Cylinder and Cryogenics Recognised Prior Learning qualification not included in this report.
OHS Training Performance Total Per Quarter for Monash University
First Aid & Emergency Preparedness
OHS Essentials
OHS Specialised
Wellbeing Training
10000
9000
783
8000
382
7000
6000
2224
1406
690
5000
4000
3000
2048
439
895
1242
439
1070
2094
1574
1982
2721
2036
1841
3033
3275
3519
1243
1246
2000
1000
397
2226
0
Calendar 2009 Calendar 2010 Calendar 2011 Calendar 2012 Calendar 2013 Calendar 2014
The table below lists the courses relevant to the above mentioned categories: First Aid &
Emergency
Preparedness





Asthma Management
Breathing Apparatus
CPR Refresher
Emergency Warden
First Aid Level 2
MUOHSC Progress Report – Qtr 4/2014
OHS Essentials
Risk
Management
 HSR training
 Essential OHS
 Hazard & Incident
Investigation
 Risk Management
 Student Project
Safety
 Risk Management
 Cryogenics
 Workplace Safety
Inspections
 Biosafety – Module 1
&2
 Chemwatch
 Cryogenics
 Ergonomics &
Manual Handling
 Gas Cylinder Safety
 Hazardous
Substances &
Dangerous Goods
 Hydrofluoric Acid
Safety
 Laser Safety
 Radiation Safety
AUTHOR: MANAGER, OH&S
Wellbeing
 Assertiveness in the
workplace
 Communicating effectively
at work
 Managing conflict
 Managing self through
change
 Managing your work,
yourself and time
 Mental health first aid
 Mindfulness for wellbeing,
resilience and
performance - staff &
students
 SafeTALK building a
suicide alert community
 Working parent resilient
program – women & men
 Family and sexual
violence
Page 12 of 13
19/02/2015 Wellbeing
Wellbeing, as part of occupational health in OHS, focuses on 4 key areas to support and improve the
health of Monash staff. These include providing a wide range of programs incorporating physical
activity, mental health, nutrition and general health. The following table shows participation of staff
who participated in at least one wellbeing activity throughout the year as a cumulative percentage of
the total tenured/fixed term staff.
Year
2014
QTR
4
Target
30%
Result
35%
Status
Achieved
Wellbeing KPI Performance 2014 (YTD)
Achieved KPI Target for 2014
2500
Below KPI target for 2014
2000
1500
1000
500
0
56.5%
223
CIO & Vice‐President (Information)
55.8%
706
Vice‐President (Services)
54.5%
391
Faculty of Education
51.1%
231
Chief Operating Officer & Senior VP
48.7%
191
Provost & Senior Vice‐President
42.6%
591
Faculty of Law
38.7%
119
Vice‐Chancellor & President
35.3%
133
Faculty of Business & Economics
32.9%
529
Faculty of Science
29.8%
463
VP (Mkting Comms & Student Recruitment)
28.2%
142
Faculty of Engineering
28.2%
387
Faculty of Information Technology
26.9%
145
Faculty of Medicine Nursing & Health Sci
26.6%
1911
Monash Student Organisations
22.1%
68
Faculty of Pharmacy & Pharmaceutical Sci
19.1%
282
Faculty of Arts
18.2%
435
Faculty of Art Design & Architecture
2.9%
102
Monash Affiliated Organisations
2.5%
40
0%
MUOHSC Progress Report – Qtr 4/2014
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
AUTHOR: MANAGER, OH&S
Number of Fixed Term & Tenured Staff in Each Area
Chief Financial Officer & Senior VP
Page 13 of 13
19/02/2015 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
14/01/2015
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
14/01/2015
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
Q13
Do all staff complete the online Monash Safety induction?
Yes
No
Q14
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)'.
Q15
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
(signing out) at the Facilities and Services kiosk. Contractors are required to wear the
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 4 of
14/01/2015
contractors registration sticker issued at the kiosk.
Q16
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?
Yes
No
Q17
Do all HDR students complete a local OHS induction that has
been developed in accordance with the OHS Local Induction
procedure?
Yes
No
Q18
Do all visitors complete a local OHS induction that has been
developed in accordance with the OHS Local Induction procedure?
Yes
No
Q19
Do all contractors complete a local OHS induction that has been
developed in accordance with the OHS Local Induction procedure?
Yes
No
Q20
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
Q21
Q22
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
Q23
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
Q24
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
Q25
Has Occupational Health and Safety been informed of evacuations
conducted?
Yes
No
Q26
Is an up to date contact list of trained first aid staff available in all
relevant public areas?
Yes
No
Q27
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
Q29
Is the assessment less than 3 years old?
Yes
No
Q30
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'
Q28
Q31
Please name the staff member responsible for maintaining the
defibrillator:
Have the required 6 monthly defibrillator checklists been completed
and records kept for 5 years as required?
Defibrillator Maintenance Checklist
Yes
No
Zoll Defibrillator Checklist
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.
A workplace inspection program is available at the OH&S website. Training in the use of
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?
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)
Possible encounters with high-risk behaviour by individuals
(e.g. Client-based services, distressed students).
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
14/01/2015
Q40
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)?
Q45
Does the CAR include corrective actions from the following
Self Audit Questionnaire, v7
Date of first issue: June 2005
Once hazards and issues are identified, corrective actions can be established which
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 8 of
14/01/2015
sources?








Q46
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
Date of next review
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
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.
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 9 of
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

Filename/ storage location of document
Reference to the central OHS Management System guidance
document the procedure is based on.
Yes
Yes
No
No
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.
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
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
Q61
Does your unit use chemicals, e.g. for work procedures, cleaning,
teaching, research, preparation of materials?
Self Audit Questionnaire, v7
Date of first issue: June 2005
Yes
No
'Using chemicals at Monash University' provides guidance to staff, students, visitors
and contractors who use chemicals at Monash University.
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 10 of
14/01/2015
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
Q75
Do you have procedures for the management of spills?
Yes
No
http://www.monash.edu.au/ohs/forms/spill-kits-laboratories.pdf
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
Q76
Is there a process for regular testing of safety showers?
Yes
No
All safety showers and eyewash facilities must be regularly flushed and checked to
ensure they are fully functional. Facilites and Services
http://intranet.monash.edu.au/fsd/contact-us.html
Yes
No
Yes
No
Yes
No
Yes
No
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.
D. Gas cylinders
Q77
Does your unit use gas cylinders?
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?
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 4332-1995 The
storage and handling of gases in cylinders and Australian Standard 2243.10-1993 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?
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.
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.
Self Audit Questionnaire, v7
Date of first issue: June 2005
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 12 of
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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
'Using ionising radiation at Monash University’ provides guidance to staff, students,
visitors and contractors who use ionising radiation at Monash University.
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
Yes
No
G. Biologicals
Q98
Does your unit use biological substances, e.g. human blood, bodily
fluids or tissues, microorganisms, animal blood or tissues, cultured
Self Audit Questionnaire, v7
Date of first issue: June 2005
'Using biologicals and animals at Monash University' provides guidance to staff,
students, visitors and contractors who use biologicals and animals at Monash
Responsible Officer: Manager, OHS
Date of last review: January 2015
Page 13 of
14/01/2015
cells, biological products derived from cells, microorganisms or
animals?
University.
If no, skip to Section H
Q99
Has your unit appointed a biosafety officer?
Yes
No
Q100
Q101
Please name:
Please provide the date of your latest OGTR Audit.
Have all corrective actions from this audit been implemented?
Yes
No
Q102
Have immunisation requirements been identified?
Yes
No
Areas that use biological substances must appoint a biosafety officer.
Procedures for Immunisation
Work Related Immunisation Requirements for Monash University Staff and Students
H. Animals
Q103
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.
Q104
If your work requires you to wear a mask, have you been 'fit tested'
(for an appropriate mask)?
Yes
No
Q105
Have the appropriate health surveillance measures been identified?
(e.g. lung function testing)
Have immunisation requirements been identified?
Yes
No
Yes
No
Q106
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