DGD14-008 Standard Operating Procedure Training, Education and Study Assistance Purpose The ACT Health Training, Education and Study Assistance Standard Operating Procedure provides a quality governance system for a consistent and coordinated approach to managing learning and development activities within the organisation. Principles of learning and development in ACT Health include: Improve the quality and safety of healthcare by providing high quality planned and integrated education and training that contributes to the skill and competence of staff, students, volunteers and contractors Provide learning and development activities to meet legislative requirements, accreditation requirements and National Safety and Quality Health Service Standards (NSQHSS) Maintain the integrity of data and reporting Comply with the national quality framework for Registered Training Organisations Implement the ACT Health objectives for learning and development set out in the Learning and Development Framework 2013. This SOP describes management processes for training, education and study support in ACT Health to ensure: Training and education is managed and reported through the centralised Learning Management System Capabiliti Training and education is monitored for quality through executive endorsement, annual review of the Education Activity Register (EAR), and evaluation Administration processes are in place to maintain quality and accountability for learning and development activities and study assistance. Scope This SOP applies to all staff, including Executives, managers, trainers/ educators and staff administering learning and development (L&D) activities. It also applies to staff who provide training to volunteers, contractors, consumers, students. The SOP includes: responsibilities for all staff, Executives, managers, trainers/educators, and staff development unit management of internal education programs including e-learning and purchase of external e-learning administration of training and education including booking, cancelling and fees provisions for access to external study including study assistance and the ACT Health loans scheme. Out of scope are: Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 1 of 15 DGD14-008 details about scholarships divisional / branch specific processes for attendance at conferences and external courses not covered by study assistance essential education information - refer to the ACT Health Essential Education policy. Responsibilities Executives Provide governance for prioritising, resourcing and ensuring the quality of learning and development Identify organisational learning and development priorities and provide input to the organisational learning needs analysis and revisions on policy Endorse programs provided in your division / branch to ensure they meet identified needs, are provided by suitably qualified staff, are evidence-based and evaluated (see Administration: Education Activity Register) Approve requests for development of training and eLearning by Staff Development Unit (SDU) on behalf of your division/ branch and purchase of external eLearning programs (see Administration: requests for training) Ensure staff in your division / branch complete essential education (refer to Essential Education Policy) Report against the ACT Health Learning and Development Framework for your division / branch. Managers and supervisors Provide access to, and monitor, your employee’s education to meet essential education, quality, risk and leadership requirements. Discuss and track learning needs in the performance planning process Update the essential education information and categories attached to a position when you create, abolish or vary it in any way using an Establishment Variation Authority Form (SDU can provide assistance). This ensures your staff records on Capabiliti show the correct essential education requirements Access reports on your employees education completion on Capabiliti - SDU provides training and access to do this Notify SDU if your staff member cannot attend booked training if they are unable to do so (see section on cancellations and fees for non-attendance) Provide fair and equitable access to external study to ensure a skilled workforce (see section on Study Assistance and other study support). Trainers and educators Provide competency based training to clinical staff to meet the requirements of the National Safety and Quality Health Service Standards (NHQHSS). Competency based training includes a way to assess and record that the required learning has taken place, and meets defined standards If you are providing programs for staff across ACT Health establish a stakeholder group for the program to ensure input from all areas and avoid duplication. Use Capabiliti for all your course records (SDU will provide you with training and access) You must sign a confidentiality agreement to maintain confidentiality of information on participants Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 2 of 15 DGD14-008 Complete an EAR form for all programs on Capabiliti (see administration) and send to SDU Ensure courses you put on Capabiliti have the required information for applicants in the notes section. This includes the learning outcomes, target group, cancellation details and trainers contact details Use Capabiliti to mark participant attendance and participants competency status folowing assessment as soon as possible after a program Advise managers as required of participant non-attendance at programs and / or competency assessment outcomes Send copies of participant attendance at courses and in-services to SDU for data entry in a timely way if you don’t have access to do it yourself. All Staff Take responsibility for identifying your learning needs and completing your education requirements Provide input to the annual learning needs analysis, and evaluation of programs you attend Make sure you monitor and update your essential education requirements If you need to cancel your attendance at a booked course, do so 5 working days or more before it starts. If you cancel less than 5 days before the program you need to discuss with the trainer or SDU or your work area may be charged (see cancellation and fees for non-attendance) Staff Development Unit Coordinate and report on all ACT Health L&D for the annual report and accreditation. Manage and evaluate policies related to learning and development Manage the organisational Registered Training Organisation (RTO) Manage, procure, and providing operational support including help desk and training for the Capabiliti Manage the organisational learning needs analysis Develop and manage eLearning Plan, develop, implement and evaluate a range of education and graduate programs Maintain and audit the Education Activity Register. Procedure Managing training and education activities and study assistance The procedures for managing training, education and study assistance are described in the following sections: Section 1: Administration, consultation and access to training and education Education activity register Evaluation of education Consultation with you Requesting training and eLearning development Buying externally produced eLearning Learning and development data and reporting Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 3 of 15 DGD14-008 Non-staff access to training New staff access to training Help and feedback Section 2: Cancellations and charges for non-attendance Cancellations and late attendance Fees for non-attendance and late cancellations Fees for courses Section 3: Study Assistance and other education support Study Assistance Loan scheme Scholarships Other support Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 4 of 15 Section 1: Administration, consultation and access to training and education EDUCATION ACTIVITY REGISTER (EAR) This is a register of all programs on Capabiliti to ensure they are monitored for quality and regularly reviewed by evaluation It applies to all programs of 3 hours or more duration, or held on a repetitive basis. Short in-service programs are exempt Educators must complete a form and update it annually – you will find it on the SDU intranet site. This outlines the program details, objectives and review date, and is endorsed by the relevant Executive Director SDU audits programs on Capabiliti annually to ensure the EAR has been submitted EVALUATION OF EDUCATION PROGRAMS Evaluate all training and education programs you provide and review them at least annually Provide evaluation reports as required to demonstrate how the program is meeting organisational and staff needs Evaluation of programs relevant to the NHSQSS to demonstrate how they contribute to quality, safety, leadership and risk management L&D DATA AND REPORTING All records of training and educaton activities across ACT Health must be managed through Capabiliti. This provides accurate data for legislative compliance, annual reporting, accreditation and essential education completion Regular reports on L&D data is provided for program evaluation, accreditation and for the ACT Health annual report Various reports are available on data on Capabiliti, including records of your training histor Managers, Executives, trainers and educators can be provided with training on accessing reports relevant for their area Other reporting can be requested by contacting the Capabiliti administrator in SDU CONSULTATION WITH YOU Doc Number DGD14-008 Learning Needs Analysis SDU conducts a training needs analysis annually as required by the NSQHSS standards and RTO standards. Everyone is invited to provide input to identify current learning priorities Risk assessments and audits will be conducted annually on programs required for legislative and accreditation compliance and to identify ongoing training needs Your ongoing evaluation and feedback also informs the learning needs analysis Committees and Stakeholder Groups Stakeholder groups are established for major programs to provide a consultation and evaluation forum Each Division /Branch and SDU are responsible for learning and development and should establish stakeholder groups to report on program development and evaluation SDU maintains an organisational Learning and Development Committee for consultation Contact SDU if you are interested in joining a stakeholder group Issued January 2014 Review Date January 2017 Area Responsible SDU Page 5 of 15 REQUESTING TRAINING DEVELOPMENT BUYING EXTERNAL ELEARNING NON-STAFF ACCESS TO TRAINING NEW STAFF ACCESS TO TRAINING Doc Number DGD14-008 Issued January 2014 If you want SDU to develop training for you (face to face or eLearning) or are considering the purchase of externally produced eLearning please complete a Training Request Form with the details including approval from your delegate. This form is available on the SDU intranet The Executive Director in the Division / Branch is responsible for final approval of a request For eLearning development, staff should also refer to the eLearning development information on the SDU intranet site, and consult with the eLearning officer in SDU Managers considering purchase or access to an externally developed eLearning program must consult with SDU prior to purchase, noting the risks and considerations for externally purchased eLearning including security risks, licensing restrictions, compatibility with Capabiliti and the ICT environment, and ability to track completion data for reporting. For Capabiliti to track progress and completion, the program must be Sharable Content Object Reference Model (SCORM) 1.2 compliant. Non SCORM compliant programs will not be made available on Capabiliti Externally purchased and hosted eLearning programs must comply with ACT Government ICT security policy to be linked to Capabiliti and compliance must be checked before purchase A Request for Training Development form (on SDU intranet) must be submitted to SDU prior to purchase as there is considerable development work to access and load external eLearning programs on Capabiliti Non-ACT Health participants may access Capabiliti as a new user to register for face to face courses. Non-ACT Health users will not have automatic access to eLearning except by request to SDU from a manager responsible for a non-staff group (eg contractors) Attendance by non ACT Health groups working within ACT Health at programs may incur a fee, except for essential education. It is up to the program owner to identify if non ACT Health staff can attend a program and whether there will be a fee for attendance Work areas managing essential education and/or orientation processes for volunteers, contractors, agency staff, locums, or students should refer to the ACT Health Essential Education Policy Responsible areas must ensure data and reporting on completion of training requirements for these groups is kept on Capabiliti. Student Clinical Placement Unit is responsible for ensuring students complete essential education requirements prior to placements and recording completion on the student placement LMS. Identify your learning needs from the information provided at orientation and by discussing with your manager as part of the workplace induction pathway. You can also refer to the Essential Education Policy. You will not have automatic access to Capabiliti until after your first pay because that is when you are entered into the HR system Chris21. To access Capabiliti to enrol in programs and eLearning before you get paid, follow this process: o Open Capabiliti and access the new user option to complete the necessary information following the prompts. o Once registered as a new user, either you or your manager must email SDU your AGS number (you will find it on the letter of offer) and the name of your approving manager before your first pay. Send this information to Review Date January 2017 Area Responsible SDU Page 6 of 15 HELP AND FEEDBACK staff.development@act.gov.au o To access eLearning, contact SDU to be manually assigned to a course SDU provides help desk support for Capabiliti during standard business hours by phone on 6244 2258 and email staff.development@act.gov.au Answers to frequently asked questions (FAQ) is on the front page of Capabiliti and on the SDU intranet site There is a link to an anonymous feedback survey on the SDU intranet site Other feedback about learning and development can be provided through SDU either by phone, email or by contacting the SDU Director. Section 2: Cancellations, charges for non-attendance and fees CANCELLING OR LATE ATTENDANCE CHARGES FOR NON-ATTENDANCE FEES FOR COURSES Doc Number DGD14-008 Issued January 2014 You or your manager must cancel attendance at a course at least 5 working days before the course date using Capabiliti or by notifying SDU or the relevant trainer. An extended cancellation period of 10-15 days may apply to high demand or fee-incurring programs. This will be identified in program notes on Capabiliti and will be determined in consultation with the Director of SDU If you arrive late at programs you may not be admitted if you miss important information and cannot be marked off as completing requirements. Your work area may be charged a non attendance fee. A charge of $300 may be incurred by the work area for non-attendance, late cancellation or late attendance. For programs with an external provider, the non-attendance fee is either $300 or the non-refundable cost of the course (if over $300). If you are unable to attend due to personal leave, you or your manager should contact SDU or the trainer so that a replacement can be identified from the waiting list. The fee may be waived depending upon the reasons for non-attendance. Work pressure is not a reason to waive non-attendance except in exceptional circumstances in consultation with the Director of SDU. Managers should consider work pressures when approving enrolment. Where non-attendance is unavoidable managers may nominate a replacement to attend. Most programs and assessments are provided free to ACT Health staff, with the exception of programs for which external training providers are engaged. Any fees for courses will be identified in Capabiliti. It is the responsibility of Executive Directors to determine if non government organisations will be charged when accessing ACT Health programs. Additional education and assessment of tertiary sector students is provided by employees of ACT Health according to details outlined in schedules attached to Deeds with the tertiary provider. Review Date January 2017 Area Responsible SDU Page 7 of 15 Section 3: Study assistance and other study support What is study assistance? Study assistance is an ACT Government scheme under the Public Sector Management Standards 2006, to support staff to acquire skills and knowledge through recognised external qualifications that will benefit the organisation and the individual. This section identifies the ACT Health provisions for study leave and should be read in conjunction with the advice and application forms available through the Shared Services customer service portal: http://sharedservices/actgovt/HRdocs/StudyAssistanceFramework.doc http://sharedservices/actgovt/HRforms.asp https://actgovssc.custhelp.com/app/answers/list/kw/studies/search/1/session/L3RpbWUvMTM4MDAwMDcyNi9zaWQvVTV6U0E1Qmw%3D Can be used for: Study that is relevant to your job, or a work function in ACT Health or to the ACT Public Service generally leading to a recognised qualification or statement of attainment under the Australian Qualifications Framework. Not used for: General non-accredited professional development activities Conference or seminar attendance Professional development or sabbatical leave covered in Enterprise agreements Financial assistance if you are receiving another form of financial assistance such as a scholarship, but you can apply for study leave Am I eligible to apply? Eligible: Permanent employees of the ACT Public Service (applies to all ACT Health staff regardless of classification) Have at least 12 months of continuous service (includes eligible transfer of service) Temporary employees with a contract of 12 months or longer If you don’t meet these conditions, consideration may be given to your application with your Executive Director’s approval. Not eligible: Employees undertaking recognised development programs such as Graduate Programs or Traineeships Casual employees and short-term temporary employees (with a contract of less than 12 months) Employees undertaking an Australian Apprenticeship Employees who may have alternate provisions in an Enterprise agreement that replace study assistance (see below) Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 8 of 15 How and when do I apply? Moving work area? What should I consider if I approve applications? Doc Number DGD14-008 Senior Specialists and Specialists Training, Education and Study Leave (TESL) and Medical Education Expenses (MEE) replaces entitlements to study leave as described in this document. Please refer to the ACT Public Service Medical Practitioners Enterprise Agreement 2011-2013 for details of TESL and MEE. Follow these steps: Discuss your proposed study assistance with your manager. It is preferable your study has been identified in your Performance Plan. You should also discuss your future requirements for study assistance for an ongoing course. Study assistance is not a right and is provided at the discretion of your Delegate. You must apply and be approved before you start your study ie before the semester or term commences. Your study leave is granted based on the date of the application. You cannot take any leave before approval or back date your application. Allow time for the approval and notification process You must apply each semester/term or when you start a new unit or study activity. This is because you may not be given study assistance to repeat failed units, and because each unit may have different time or cost requirements Read the application guidelines and complete the form on the Shared Services customer portal (see links above) Shared Services will send you formal confirmation of study assistance approved by the Delegate for that semester and keep a record of all study assistance granted. If you are moving between work areas or from another Directorate and have previously had approved study assistance, you should discuss any requirements for continued study assistance with the receiving manager or delegate and submit a new application. Approval of the new application will be at the discretion of the receiving work area delegate giving consideration to whether discontinuing study assistance may result in any disadvantage or hardship to you. When you approve an application: Check you have the appropriate delegation to approve the application – see who can approve in right column below Consider consistency and equity in your allocation of study assistance, and any special circumstances or hardship Consider the relevance of the study to the applicant’s current position, future career development and align with their Performance Plan Check the application for accuracy, and note any future need for study assistance to continue the course Decide what study assistance will be given – there is no automatic entitlement Discuss reasons for study leave non-approval or the amount of study assistance granted with the applicant Issued January 2014 Review Date January 2017 Area Responsible SDU Page 9 of 15 STUDY ASSISTANCE ALLOWANCES AND APPROVALS This describes the RECOMMENDED MAXIMUM ALLOWANCES for study assistance you can apply for in ACT Health. There is no automatic entitlement to study assistance. Whether you are provided study assistance is at the discretion of your approving delegate after consideration of equity and fairness in allocation of assistance, your performance plan and development needs, and work area requirements. Part-time staff applicants: calculate the provisions pro-rata, based on your part time ratio – check with your manager if you are not sure. (For example, someone who works 0.5 FTE would be able to apply for 50% of these recommended provisions). APPROVAL AS A STUDENT This is the basic level of support that all applicants require before additional assistance can be granted. Approved ‘student’ status entitles you to leave to attend compulsory examinations plus reasonable travel time for attendance examinations, even if no other leave is granted. Applicants granted ‘student’ status may be covered under the Work Health and Safety Act 2011 and/or the Safety Rehabilitation and Compensation Act 1988 when attending study related activities- this can be checked with the Director, Employment Services, People Strategy and Services Branch. PAID STUDY LEAVE You can apply for up to 4 hours per week paid study leave for the period of time you are enrolled in your current unit(s), usually per semester or term, unless you are enrolled in a year-long subject/unit. Multiply this by the length of your semester/term for the total amount to put into your application form. Don’t include breaks or holidays in your calculations. Example: 4 hrs per week x 15 weeks in your semester = apply for up to 60 hours of study leave. Options for taking your leave: As a weekly amount eg to attend local classes during work time Use it cumulatively or ‘bank ’it to take in larger amounts at a time. For example if you are studying distance, you may wish to save your weekly amount and take a day off for study purposes instead. Or if you need to attend study days interstate, you can save up your hours to use for this purpose. Only take the total approved amount per semester (or period of study for your enrolled unit/subject). You can’t carry over any study leave to the next application / semester. Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 10 of 15 WHO CAN APPROVE APPLICATIONS? Approval as a student and/or approval of paid study leave, travel time and exam leave: approved by the delegate/ manager who has delegation to approve the applicants leave. Study assistance is recommended by the applicant’s supervisor and approval is given by the appropriate delegate (see Human Resources Delegations Manual ref 278). To provide more than the maximum recommended allowances, seek approval from the Executive Director How you take your approved study leave must be negotiated and agreed with your manager considering the requirements of your course, and the requirements of your workplace. TRAVEL TIME You may also apply for additional reasonable travel time to attend local classes. Work out the time to and from your study institution and your workplace. Calculate this for each week you will be attending classes eg 1 hour travel per week You may also apply for reasonable travel leave for compulsory attendance at non-local institutions. Travel time should not exceed the equivalent of 3 hours per week. EXAM LEAVE If you have approval as a student, you may have leave to attend compulsory examinations, even if you don’t receive any other paid study leave. You must notify your manager as soon as you have your exam time-table to negotiate this. LEAVE WITHOUT PAY (LWOP) You can apply for up to 12 months leave without pay for study purposes. LWOP for study purposes is subject to the same conditions as other LWOP. Before applying, obtain advice from Shared Services Payroll about any effects on other leave entitlements and superannuation. FINANCIAL ASSISTANCE You can apply for reimbursement of up to 65 % of study costs, including HECS-HELP, FEE-HELP, AUSOS-HELP, compulsory course fees and student administration / general service fees. More than 65 % may be granted with the agreement of the Director General. If you are a scholarship recipient you are not eligible to apply for financial assistance through this scheme Financial assistance does not apply to the costs of travel, accommodation, student union fees, textbooks or other costs (e.g. graduation fees) This financial support is refunded after successful completion of your unit(s), it is not pre-paid It is reimbursed from your work area cost code. You can obtain the form to claim your reimbursement on the Shared Services portal: https://actgovssc.custhelp.com/app/answers/detail/a_id/926 Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 11 of 15 As above As above Leave without pay (LWOP) Up to 3 months - approved by the applicant’s delegate. More than 3 months - approved by the Director General (see Human Resources Delegations Manual ref 187). Must be approved by the Executive Director of the Division / Branch (see Human Resources Delegations Manual ref 278). How are records managed and reported? What if I’d like a decision reviewed? HELP Approving delegates must keep a record in their own area of study assistance taken by their staff members Staff members taking study leave should record this on their time sheets / flex sheets where appropriate Shared Services Training and Development keep central records of all approved applications, and the amount of study assistance granted. These records are provided to ACT Health for annual reporting and 6 monthly reports to Executive Council. If you believe that your application was rejected without reasonable justification, or will lead to undue hardship, you can request that the decision be reviewed: An attempt should be made firstly to resolve the matter with your manager and/or director, ensuring that all issues were taken into consideration in the decision-making process If this does not resolve the issue, the Executive Director, People Strategy and Services Branch (or his/her delegate) may be involved as an independent person in reviewing the decision If you have any questions about study assistance please refer to: How to use the application form: Shared Services customer service portal ACT Health provisions: Staff Development Unit Reviews of decisions on an application: seek advice from Employee Relations, People Strategy and Services Branch Other support for external study LOAN SCHEME SCHOLARSHIPS PROFESSIONAL GROUPS Doc Number DGD14-008 The ACT Health Loan Scheme for Tertiary Study (LSTS) is a loan available for all staff to support tertiary education. The loan provides advanced payment of course fees which must be repaid to ACT Health through regular payroll deduction within the semester of study. Deductions will be a fixed fortnightly amount as determined by Shared Services Payroll. Full repayment must be made by the end of the semester The loan does not apply to student union fees, repeat subjects, late fees, and other associated costs The application is approved by the work area Executive and then submitted with supporting documentation to SDU for processing This form is forwarded by SDU to Finance who provide a cheque or direct deposit into the applicants bank account. Finance requires a minimum of ten (10) working days to process payment following approval. The form and further information is available on the SDU intranet site Scholarships may be available for some tertiary study upon approval of application to relevant scholarship funds Scholarships are advertised for application periodically and enquiries should be made to the relevant area Information on scholarships is available on the ACT Health intranet under Health Professionals, Nursing and Midwifery and Allied Health, and also by searching for ‘scholarships’ Check your current Enterprise agreement for other information on learning and development that may apply to a professional group. These documents are available on the ACT Health intranet Issued January 2014 Review Date January 2017 Area Responsible SDU Page 12 of 15 CONFERENCE AND EXTERNAL COURSES Doc Number DGD14-008 Follow your divisional / branch processes – divisional / branch specific processes are not covered in this document Issued January 2014 Review Date January 2017 Area Responsible SDU Page 13 of 15 Evaluation Outcome Measures Organisational governance processes for learning and development are implemented and monitored annually including the Education Activity Register; records and data, information and reporting using Capabiliti, stakeholder consultation, evaluation, and reporting. Method The following activities will be measured each year and reported on by an audit process: The number of programs on Capabiliti that have an annually updated entry in the Education Activity Register demonstrating approval by Executive Directors, evaluation and review A calendar of education and training opportunities are provided for staff on Capabiliti, the intranet and notice boards Data on the uptake of study assistance is provided 6 monthly to Executive Directors Council A learning needs analysis is conducted annually Data on uptake of education and training is reported in the ACT Health annual report Related Legislation, Policies and Standards Legislation Human Rights Act 2004 National Vocational Education and Training Regulator Act 2011 Privacy Act 1988 Public Sector Management Standards 2006 Policies Acceptable Use of ICT Resources Policy Essential Education policy Privacy and confidentiality policy Student and Trainee Clinical Placement Policy Learning and Development Framework 2013 Volunteer Policy Standards National Safety and Quality Health Service Standards Student and Trainee Clinical Placement Standard operating procedure Standards for NVR Registered Training Organisations 2011 Definition of Terms Capabiliti - Learning Management System or Training Management System refers to an information management system to manage all learning and development activities, information, data and reporting across ACT Health. Competency: The application of knowledge, skill and appropriate behaviour to a required standard in a given context and across a range of different circumstances. Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 14 of 15 Education Activity Register: A record of training that details elements of the program such as the facilitator, learning objectives, program plans, references to establish up to date best practice, research and executive endorsement. The register is to be updated annually. ELearning: Any learning material presented in an electronic format. Essential Education “Essential Education” is mandatory training and includes key knowledge and skills considered essential for staff working within ACT Health. Trainers/educators: ACT Health and Shared Services ICT staff employed in all divisions / branches within ACT Health providing education or training either as a primary or secondary function in a variety of specialities. SCORM (Sharable Content Object Reference Model): An international standard for eLearning that allows automated tracking of a learner’s performance (i.e. course progress, completion and competency). SCORM 1.2 compliant eLearning courses integrate with Capabiliti. References National Safety and Quality Health Service Standards 2011 Disclaimer: This document has been developed by Health ACT , specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and ACT Health assumes no responsibility whatsoever. Doc Number DGD14-008 Issued January 2014 Review Date January 2017 Area Responsible SDU Page 15 of 15