LMIN PR 07 Control of Documents & Records Procedure [00]
Control of Documents & Records
PROCEDURE
Integrated Management System
ISO 45001:2018 | ISO 14001:2015 | ISO 9001:2015
LMIN_PR_07 | REV00 | JUNE 2019
Integrated Management System PROCEDURE
DOCUMENT INFORMATION
Name of Procedure Control of Documents & Records Procedure
Description of Procedure
Procedure Applies To
Procedure Status
Approval Authority
Governing Authority
Responsible Officer
Effective Date
The ISO standards require that documented information created or updated in the scope of the
Integrated Management System (IMS) must be properly identified and described, also considering its content presentation, and media used. All documented information must go under proper review and approval procedures to ensure it is fit for its intended purpose.
Company-Wide IMS-Specific Project-Specific
New Document Review of Existing Document
Managing Director
Audit & Risk Committee
IMS Manager
June 2019
Date of Procedure Review June 2021
Related Legislation, Policies,
Procedures, Guidelines or Protocols
IMS Policy
Risk Management Framework
DOCUMENT HISTORY & CONTROL
Document is NOT controlled in printed format. Consult latest Master Document Register to verify the latest revision.
Rev Date
00 JUN19
Author Initials
G Van Heerden
Approval No Brief Change Description
DA_19.00 Initial issue
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Integrated Management System PROCEDURE
TABLE OF CONTENTS
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Integrated Management System PROCEDURE
OVERVIEW
The
Control of Documents and Records (Documented Information) Procedure
45001:2018, ISO 14001:2015 and ISO 9001:2015 International Standards.
is governed by Clause 7.5 of the ISO
ISO documentation is comprised not only of the documents and records required explicitly by the standard, but also of the documents and records the Company finds necessary to execute its activities and processes.
The volume of Company documentation is affected by many factors; the complexity of its processes, products, and services; compliance obligations; and also, by the competence of the employees.
For proper control of documented information, the Company is to consider the provision of processes regarding the distribution, retention, access, usage, retrieval, preservation and storage, control, and disposition of documented information.
It should also be noted that there must be controls in place to prevent the unintentional use of obsolete information.
1 PURPOSE & SCOPE
The procedure details the process for control of IMS documents and records to ensure they are adequately controlled in terms of approval, review, changes, availability, indexing, archiving and records control.
The procedure applies to the Company and all its employees.
2 REFERENCES
ISO 45001:2018, ISO 14001:2015 and ISO 9001:2015 Clause 7.5
Statutory and Regulatory Requirements
3 DEFINITIONS & ABBREVIATIONS
3.1
Document - A piece of written, printed, or electronic matter that provides information or evidence or that serves as an official record.
3.2
Records - Information in any form; hardcopy or electronic, created or retrieved and maintained by the
Company or designated person in the transaction of business, or the conduct of affairs to be kept as evidence of such activity.
3.3
Controlled Document - A reference document which, through the course of its lifecycle may be reviewed, modified and distributed several times. Examples of a controlled document include; policies, procedures, technical drawings, specifications, operational control documents, plans and contracts.
3.4
Documented Information - Information that is required to be controlled and maintained by the Company and the medium on which it is contained.
3.5
Form - Printed, typed, or electronic document with blank spaces for insertion of required or requested information (e.g., checklist, inspection form, etc.).
3.6
Archive - The whole body of records of continuing value of an organisation — ‘corporate memory’ .
3.7
Disposal - A range of processes associated with implementing appraisal decisions. These include the retention, deletion or destruction of records in or from record keeping systems. They may also include the migration or transmission of records between record keeping systems, and the transfer of custody or ownership of records.
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Integrated Management System PROCEDURE
4 ROLES & RESPONSIBILITIES
4.1
Process Owners (heads of departments) - to ensure that this procedure is implemented and maintained in their area(s) of control, and to demonstrate the effective planning, operation and control of workplace processes.
4.2
Document Control Department - for controlling the IMS documents, records, procedures and work instructions related to the IMS, and all internal and external documents required by the IMS.
4.3
IMS Manager - for ensuring that the latest versions of relevant documents are available at the point(s) of use, that these documents are legible, and that they are understood and followed. They are also responsible for reviewing and responding to document change requests in a timely manner.
4.4
Workplace Engineering - for control of external and internal drawings (e.g., blueprints, schematics, and technical drawings), bills of quantity (BOQ), and customer specifications and requirements documentation.
5 PROCESS DESCRIPTION – CONTROL OF DOCUMENTS
5.1
IMS Documents a) The IMS Coordinator (or designee) shall oversee the preparation, review, secure authorisation, issue and amendment of key IMS documents. b) A Master Document Register (MDR) shall be used to identify the latest issue of controlled documents.
It is the responsibility of the IMS Coordinator to maintain the MDR and controlled document files. c) While hardcopies of the IMS Policy Manual and associated procedures may be kept as a reference, the master-controlled copies reside in softcopy only. Only the latest issue of any document is held in the reference or master soft copy files. d) Procedures are prepared by the IMS Coordinator and respective Process Owners, and formally approved by the Managing Director; evidenced by signature on a Document Approval Form for each controlled document. e) Each IMS document includes a title, reference number, revision number, issue date and page number. f) The IMS Coordinator to ensure that all released IMS documents are updated in a controlled manner and superseded documents are withdrawn from the master document folder on the system. Document change is carried out in accordance with section 5.4. g) The IMS Coordinator maintains the MDR identifying the issue status of procedures and related controlled documents.
5.2
Document Creation, Formatting & Numbering a) Creation of New Documents i) Approved documents shall be listed in the MDR; ii) Revision history to be determined through a revision history table inside each document (e.g., procedure, legal guidance or work instruction); iii) A document will be considered as official once being saved in PDF format and retained by the
IMS Coordinator; and iv) Refer to appendices for detailed document formatting and numbering. b) Amendment of Existing Documents i) Any proposal of revision to an existing controlled document must be done through the IMS
Coordinator;
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Integrated Management System PROCEDURE ii) A marked-up (or redlined) hardcopy, or Tracked Changes electronic version of the relevant document to be sent to the IMS Coordinator, who will send it out for review and approval; and iii) Revision history of the amendment to be updated in the MDR.
5.3
Document Review & Approval a) New IMS policies and procedures must be reviewed by the IMS Manager and approved by the MD. b) Company-specific documents are to be reviewed by the Process Owners and approved by the
Operational Executive / Process Owner (as agreed). c) Company-specific / Workplace-specific approved documents MUST be forwarded to the IMS
Coordinator to be registered in the IMS. d) The IMS Coordinator will maintain a electronic folder on the company server, for the latest soft copy master versions of documents. This file set on the server is subject to data backup. New or revised documents are placed into that folder, setting each file’s permission to READ ONLY, or converting the released versions to a non-editable file format. e) Any previous soft versions are then moved to a separate folder identified for obsolete documents which are kept for historical purposes. f) IMS Documents must be reviewed biennially.
5.4
Document Changes & Revisions a) Upon the need to make an amendment, the document is revised accordingly by the IMS Coordinator and the issue level of the document raised to the next sequential number. b) Amendments are shown in italics with documents to give a visual indication of the amendments from the previous issue. c) The document revision table is then completed 'detailing the date of amendment, the new revision status and brief details of the change, including page and / or section references. d) The revised document is then electronically approved by the IMS Coordinator, the obsolete copies withdrawn and replaced by the updated version in the master document folder on the system; the
MDR is also electronically updated. e) On subsequent updates, the previous amendment is ‘accepted’ (changed to standard text) so only new amendments are highlighted. f) Changes to documents go through the same steps as original issue, except that their revision level is advanced upon approval. g) Any changes to documents that require customer or regulatory authority review and approval shall be submitted accordingly, and not implemented until such approval is obtained. h) If document changes require customer or regulatory approval prior to implementation, this will be obtained in writing. When processes are changed, the appropriate documentation shall be updated, with a change history updated to reflect the reason for the change. i) Re-evaluation, inspection (where applicable) or internal auditing will confirm the effectiveness of changes.
5.5
Documents of External Origin a) For external documents, such as standards or third-party specifications which are referenced in a customer contract, these documents may be maintained without control, provided that the revision of the document on file matches the revision indicated by the customer. Where the customer provides no revision number, the latest (most recent) revision shall be assumed. b) For external documents, such as standards or third-party specifications which are not referenced in a
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Integrated Management System PROCEDURE customer contract, these must be controlled. Such control requires that the Workplace Document
Controller, or responsible manager, obtain the latest version of the document, and maintain it on the workplace server (for electronic versions) or in a binder of controlled external documents (for hardcopies). Like other controlled documents, these may not be edited or copied. c) Third party specifications and drawings, including those of the customer, are to be controlled as per this procedure. d) External documents for non-critical use, such as user manuals, reference books, marketing materials, and supplier directories are not controlled. e) External publications may be documents, industrial standards and specifications which include ISO
Standards, Codes of Practice, etc., and other publications as relevant. f) These documents are checked annually via the Internet to ensure the latest version is in use. External documents such as Standards or Codes of Practice are also listed on the MDR where appropriate. g) Customer supplied documentation is reviewed on receipt and is maintained in accordance with this procedure.
5.6
Document Distribution a) Controlled documents will be available via the intranet for all employees. Employees to receive training on the file and folder locations for most current documents.
5.7
Computer Security a) Key office computer information resides on a shared server which is backed-up. The back-up is carried out daily / weekly and current back-up is stored onsite in the company fire-proof safe for security. b) An anti-virus program and Internet security is installed to protect all incoming data from corruption and unauthorised access. Any discs of external origin are virus checked before use in the company systems.
5.8
Obsolete Documents a) Obsolete documents are, depending on type, either retained for the lifetime of the related product / service (taking into account regulatory requirements and record retention periods) or promptly removed from use by the IMS Coordinator and deleted. b) Retained obsolete documents are clearly identified as ‘obsolete’ by electronic storage location / access restriction or physical marking, as appropriate, to prevent inadvertent use.
5.9
Forms a) Forms are a special kind of document that may be photocopied as needed. Furthermore, forms do not require an approval signature. Process Owners are responsible for creating and using forms in their areas. b) A softcopy of each approved form must be sent to the IMS Coordinator for inclusion in the document control area on the intranet, and for inclusion in the MDR.
6 PROCESS DESCRIPTION - CONTROL OF RECORDS
6.1
Electronic Records a) Electronic documents have the same status as paper documents. Both electronic and paper documents are bound by the same legislative requirements and are subject to the same degree of confidentiality and care. Therefore, electronic records are to be managed as an integral and routine part of record keeping.
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Integrated Management System PROCEDURE b) Storage of electronic records that contain evidence of official business transactions should be backed up and migrated to new systems or transferred to off-line storage such as CD-ROM for longer-term retention. Strategies should be developed to ensure that these records remain accessible and useable in all future generations of software, for the entire period of their retention. c) Destruction of records stored on magnetic media such as compact disks or flash drives must be destroyed by reformatting at least once. Deleting files from magnetic media is not sufficient to ensure the destruction of the records. Backup copies of the records must also be destroyed. d) Records held on optical media, such as rewritable disks, must be destroyed by cutting, crushing or other physical means.
6.2
Creation of Records a) All employees are required to create full and accurate records which adequately document the business activities in which they take part. b) Records should be full and accurate to the extent necessary to: - i) Facilitate action by employees, at any level, and by their successors; ii) Make possible a proper scrutiny of the conduct of businesses by anyone authorised to undertake such scrutiny; and iii) Protect the financial, legal and other rights of the organisation, its clients and any other people affected by its actions and decisions.
6.3
Control of Records a) Version control i) Earlier versions (i.e. drafts) of a document may be deleted once the previous versions are no longer needed to create future records; and ii) Drafts that must not be disposed of are those that document significant decisions, reasons and actions and contain significant information that is not contained in the final form of the record.
This applies to both paper and electronic drafts. b) Security i) Records must be made accessible to authorised users. Officers of the Company enacting the normal course of their duties must have access to relevant records of the Company; and ii) Personal information about Company employees must be secured within all levels of Company records (For further details on handling personal information refer to the Company Privacy
Statement). c) Desktop Records Storage i) Active records generated and used on a daily basis to be filed / boxed and Registered as per the approved Records Numbering Schedule for each workplace; ii) Filing cabinets are used for storage of files / boxes and spine labels must conform to the
Company Standard; iii) Current records are generally kept at desktop for one (1) year, after which it is considered ready for archive storage. At this time records filed in Lever Arch Files must be transferred to individual or bulk boxes, and the spine identification labels duplicated for each set of records; and iv) Boxed records are handed to the respective Archive Champions for registering and placing into archives.
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Integrated Management System PROCEDURE
6.4
Records Retention Periods a) Due to various legislative requirements, documents must be retained for a certain number of years, depending on the legislation it represents; and b) Each the Company or shared service department to compile a schedule referring to the legislation and identifying the timeframe that certain documents have to be kept.
6.5
Electronic Data Back-up a) The controls described in this section are not technically exhaustive but provide a guideline to data control integrity, which to be maintained by company IT services or workplace appointed individual. b) The Process Owner to make the necessary arrangements for data backups from all relevant personal laptops / computers on a bi-weekly basis. Backups may be done via tape streamers, CD / DVD or external hard drives and must be taken / stored off-site. This is necessary for continuation of work with the least amount of disruption as a result of theft, fire or any other unforeseen incident. c) At fixed work places such as the Company Head Office data to be backed-up incrementally daily, with a weekly full backup of the following: - i) Employee Personal Drives on the server; ii) Specific folders containing management system documents or other information; iii) The financial system database; iv) Backups to be stored off-site or in a fireproof safe. d) An antivirus package, including firewall protection to been installed on all personal computers and is maintained by the IT service department. This system must automatically update on logging on to through the Local Area Network. e) In the case of antivirus protection on remote workplaces where logon to the local area network is not possible; Process Owners must make arrangements for the updating of such programs.
6.6
Archiving Records a) General Archiving i) Records should be stored in conditions that are clean and secure, with low risk of damage from fire, water, dampness, mould, insects and rodents. They should also be kept away from direct sunlight and other sources of light and heat; ii) The storage area should be well ventilated and ideally maintained at a stable temperature and humidity; iii) Records in non-paper formats such as photographs, maps or computer disks require specialised storage conditions and handling process that take account of their specific physical and chemical properties; iv) Irrespective of format, records of continuing value require higher quality storage and handling to preserve them for as long as that value exists; v) Depending on the quantity of records sent for archiving, Archive Champions may make use of external service providers for the storage of the Company archives. Metrofile is recommended for this purpose; and vi) Archive Champions to ensure that the respective Records Retention and Disposal Schedules for each individual Company or Shared Service Department is maintained and safety stored on the Company Server.
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Integrated Management System PROCEDURE b) Packing of Archive Boxes i) Make sure you have enough space to spread out and allocate adequate time to the archiving process; ii) Two types of archive boxes can be used namely individual boxes (one lever arch file into one box), or the multiple file boxes (six lever arch files into one box); iii) When using single boxes, records must be transferred to the box and secured with the pins and backing board to keep records together; iv) When using multiple boxes, records that are in lever arch files must be taken out of the files and placed in a plastic bag (see Appendices for example). In this case, ensure you record the file spine label information on a sheet of paper and insert this sheet of paper into the plastic bag with the file contents (on top of the papers). This will identify the contents of the bags; v) Each box to have its own Archiving Register (PR_07_F09) with, amongst other information, the responsible persons, brief description of the job and subject matter, etc., all in accordance with the Company Records Numbering Schedule (see PR_07_F08); vi) Record the identification of each sealed bag onto the Archiving Register (see form PR_07_F02) so it is known what’s in the pile and the box . Make a copy of the Archiving Register for the inside of the box later before closing it; vii) Ensure bags are sealed and place approximately 6-8 plastic bags (contents of 6-8 lever arch files) into one box. Repeat the process until all records are boxed; viii) Make sure the boxes are not over packed. One should be able to fit one’s hand into the box without damaging the records and the lid must be able to close properly; ix) Place a copy of the box Archiving Register indicating the contents of the box inside the box.
This form also carries the box number; thus, the required information of this form must be written onto the spaces provided on the outside of the boxes; x) All boxes for a workplace are entered into the Master Archiving Register for reference; xi) The range of records for destruction should not be more than 2-3 years in any one box; xii) If you can’t find a code in the Company Records Numbering Schedule for a particular folder, contact the IMS Department for assistance. c) Moving Boxes to Archive Storage i) Once records have been boxed, transfer boxes to the archiving facility in concurrence with the
Archive Champion (either Intermediate, Head Office, Regional Office, or external facility) as determined by the Managing Director; ii) Once received at the archiving facility, the individual company Archiving Champion allocates space in the archives for the boxes. Boxes are then off-loaded and placed into the shelves in a manner that ensures the file content identification is visible; iii) Archive Champions to compile a Master Archive Register (form PR_07_F10) from the Archiving
Registers for ease of reference and control; iv) Records are not to be removed from the Archives without the knowledge of the Archiving
Champions in charge of maintaining the archives; v) Site generated records are to be maintained for a minimum period of five years, the Archive
Champions in charge of maintaining the archives is to monitor the expiry date and inform the
Company CEO / MD upon expiry; vi) Upon exp iry, the archived files’ retention period is to be reviewed, along with the file contents and a decision is to be made on whether to dispose of or retain the files. Records are disposed
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Integrated Management System PROCEDURE only after completion of the Request for Destruction of Records authorised by the company highest level of authority; vii) Electronic records are to be archived in the same way as above; and viii) Should off-site archiving become necessary the Company recommends Metrofile to be utilised.
6.7
Disposal and Destruction of Records a) Employees ma y only destroy or dispose of records in accordance with the Company’s Records
Numbering Schedule. b) The Records Numbering Schedule provides a listing of routine administration, personnel, accounting, operational and property records across the Company. c) Where records are scheduled for destruction this should be undertaken by methods appropriate to the confidentiality status of the records. All Company records approved and eligible for destruction must be destroyed under confidential conditions, unless the material is widely published. If employees are uncertain of the status of a record, it should be treated it as confidential and destroyed under confidential conditions. d) Confidential records should be destroyed as follows: - i) Destruction of paper records - Paper records must be shredded in the presence of the Archive
Champion, after completion and authorisation of a Request for Destruction of Records. They must never be placed in unsecured bins or rubbish skips; ii) Destruction of magnetic media - Records stored on magnetic media such as hard drives or flash drives must be destroyed by reformatting at least once. Deleting files from magnetic media is not sufficient to ensure the destruction of the records. Backup copies of the records must also be destroyed; and iii) Destruction of optical media - Records held on optical media such as rewritable disks must be destroyed by cutting, crushing or other physical means.
6.8
Audit and Review a) All record systems may be subject to audit and review to ensure compliance with legislative requirements and with the requirement of this procedure. b) To accommodate changes in legislation, technologies, programs and resources available to the
Company this procedure is to be reviewed on an annual basis.
7 APPENDICES
Appendix A - Document Numbering Standard
Appendix B - Document Formatting, Look and Feel Standard
Appendix C - Records Retention Schedule
Appendix D - Archive Packaging Standards
8 ASSOCIATED TEMPLATES
PR_07_F01 Template - Master Document Register
PR_07_F02 Template - External Document Register
PR_07_F03 Template - Document Approval Form
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Integrated Management System PROCEDURE
PR_07_F04 Template - Document Change Notification Form
PR_07_F05 Template - Document Acceptance Declaration Form
PR_07_F06 Template - Document Transmittal
PR_07_F07 Template - Document Transmittal Register
PR_07_F08 Template - Records Numbering Schedule (Example)
PR_07_F09 Template - Archive Register
PR_07_F10 Template - Master Archive Register
PR_07_F11 Template - Request for Destruction of Records
PR_07_F12 Template - File Spine Labels (Example)
See Appendices
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Integrated Management System PROCEDURE
Appendix A
DOCUMENT NUMBERING STANDARD
The Company uses t he following numbering system to unique l y ident i fy i t s controlled documents: -
Policies XX_PO_xx, where XX is the departmental or company code (see Appendix E) and xx is a sequential number starting with 01 for Group Executive Chairman & Chair or MD approved policies.
Procedures XX_PR_xx, where XX is the departmental or company code (see Appendix E) xx is a sequential number starting with 01 for IMS procedures.
Legal Guidance XX_GD_xx, where XX is the departmental or company code (see Appendix E) xx is a sequential number starting with 01 for IMS guideline documents.
Internal Standards XX_IS_xx, where XX is the departmental or company code (see Appendix E) xx is a sequential number starting with 01 for IMS procedures.
Operational Documents XX_WI_xx, where XX is the company abbreviation, and xx is a sequential nu m ber starting w i th 01 for company-specific work instruction. This category may include work instructions (WI), safe operating practice (SOP), method statements
(MS), and legal guidance (LG).
Forms/Records Fxx, each Fxx number will have a prefix (e.g. PR_00_F00) of the document it belongs to and Fxx denotes
Form and a sequential number starting with 01 for forms relating to each document. The revision status of forms will be the same as for the document it belongs to.
Letters / Correspondence These will be numbered according to the individual records numbering schedules.
DEPARTMENTAL / COMPANY IDENTIFICATION CODES
Departmental Name
Group SHEQ
Safety & Health
Environment
Quality Assurance
Quality Control
Operations
Purchasing
Tendering
Human Resources
Finance
PU
TE
HR
FI
Abbreviation
GS
SH
EN
QA
QC
OP
Departmental Name Abbreviation
LG
LB
LC
LM
LP
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Integrated Management System PROCEDURE
Appendix B
DOCUMENT FORMATTING, LOOK & FEEL STANDARD
POLICIES – Policies shall include a consistent template, indicating the document number, revision and effective date at the bottom right hand corner in 8pt. The Company Logo will appear on the top left of the document at W50cm x H18.2cm, a width to height ratio of 2.75.
PROCEDURES – Procedures, Legal Guidance and Internal Standards shall include a consistent template as illustrated on the front page of this document, with a document control page. Paragraph formatting to adhere to the following paragraph numbering styles: -
1 MAIN PARAGRAPH HEADER – 11pt bold number, zero left indentation and capitals description with 1cm indent
1.1
Sub-header – 9pt normal number at 1cm indentation and bolded description with 1cm indent a) Sub-sub wording - 9pt normal number at 2cm indentation and normal wording with 0.63 indent. This sub-subwording could become bold if it is a header for the following indented description i) Sub-sub-sub-wording - 9pt normal number at 3cm indentation and normal wording with 0.63 indent.
• Sub-sub-sub-sub-wording - 9pt normal number at 3.63cm indentation and normal wording with
0.63 indent.
METHOD STATEMENTS AND FORMS / TEMPLATES shall include a consistent template (Title Block) as illustrated in the below forms with the title in the top left corner, capped at 16pt bold and the document numbers and revisions at 7pt italic, capped and normal.
The company Logo to appear on the top right corner with a width to height ratio of 2.75. The logo size shall be W35cm x H12.7cm.
All documents will utilize the Leelawadee font, except on the front page of multi-page documents, where Maiandra MD will be used.
The Title Block in Method Statement s and Forms / Templates uses 18pt Bold. The paragraph spacing of text will be zero (0 pt) ‘Before’ and 6pt After with Line Spacing of 12pt.
The body of all documents utilises the Leelawadee font at 9pt, except for the main paragraph header which is 11pt. Policies,
Procedures, Guidance Documents and Internal Standards alignment is a full justification, Method Statements are left justified. Page
Margins shall be 1.5cm all round.
All Policies shall begin with ‘Intent’ and may also include additional section s such as Policy, Acceptable Use, Definitions, and Violations.
Procedures, Guidance Documents and Internal Standards shall begin with ‘Purpose & Scope’ and will also include Definitions &
Abbreviations, Roles & Responsibility, Process (body of document), References and Appendices.
Each document file name will follow the sequence of the number, followed by the type of document, colon, the name and the revision number in square brackets, e.g. GS_PR_12 Procedure – Document Control [03].
The Company uses a document naming principle that is descriptive and to the International Standards requirements, as well as revision numbers and effective dates.
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Integrated Management System PROCEDURE
Appendix C
RECORDS RETENTION SCHEDULE
Record Type
Accounts Payable ledgers and schedules
Accounts Receivable ledgers and schedules
Annual Audit Reports and Financial Statements
Annual Audit Records
Annual Plans and Budgets
Bank Statements and Cancelled Checks
Employee Expense Reports
General Ledgers
Interim Financial Statements
Notes Receivable ledgers and schedules
Investment Records
Internal Audit work papers and findings
Type
Paper & Electronic
Appendix D
ARCHIVE PACKAGING STANDARD
The following archive boxes must be used for all types of archiving: -
Retention Period
7 years
7 years
Permanent
7 years after completion of audit
2 years
7 years
7 years
Permanent
7 years
7 years
7 years after sale of investment
7 years after completion
Disposition Method
Shredding / Formatting
Single Box
End of Document
Multiple Box
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