Butrovich Building
910 Yukon Drive, Suite 106
PO Box 755240
Fairbanks, AK 99775-5240
www.alaska.edu/risksafety
System Office of Risk Services
Phone: (907) 450-8150
Fax: (907) 450-8151
Compliance Assistance and Assurance Program
Gap Analysis - Levels
The Environment, Health and Safety (EHS) Gap Analysis is an assessment process established by the
Risk Services Team to assess the compliance status of University operations and to facilitate the
identification of program strengths and weaknesses related to occupational and environmental safety
performance. Four Levels have been developed to distinguish the complexity of the scope of the reviews
and the responsible project leads. Following is a description of each level:
LEVEL ONE GAP ANALYSIS
PROJECT LEAD: MAU EHS department head or designee
DESCRIPTION:
A Level One Gap Analysis may be requested or scheduled by either the MAU EHS department or the affected
department. A team of two or more members will conduct the Level One Gap Analysis. Each team will consist of
at least one staff member from the MAU EHS department and one staff member from the department.
A brief opening conference will kick off the beginning of each Level One Gap Analysis to explain to managers
and supervisors the objectives of the analysis. A closing conference at the conclusion of the analysis will provide
a verbal summary of the conditions found and possibly some preliminary suggestions.
REPORTING FORMAT:
REPORTING TIME FRAME:

1st Report :
30 days from closing conference
Response from
Department head:
Subsequent
Report(s):
30 days from receipt of 1st report



Project Lead produces written report with executive
summary to department head (See Attachment 1 for
Gap Analysis Check List.)
Identify all legal (state and federal) compliance
problems
Identify all environmental, health and safety issues
that are not in compliance with Regents’ policy,
University, and/or specific program requirements
Other recommendations
Follow up reports continue every
30 days until all corrective
actions are addressed
REPORT DISTRIBUTION:






Manager responsible for the area under assessment
Executive level department director
Vice Chancellor for Administration
MAU EHS Director
SW EHS Representative
Intelex database (report copy as well as for on-going management of non-compliance items, if any)
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LEVEL TWO GAP ANALYSIS
PROJECT LEAD: As determined by MAU
DESCRIPTION:
A Level Two Gap Analysis is an assessment that may include team members that are not EHS professionals.
Level Two reviews are less formal than Level One and are routine in nature. This Level may be in the form of a
Building Blitz or a Program Compliance Assessment using the UA Workplace Assessment Questionnaire.
REPORTING FORMAT:
REPORTING TIME FRAME:


1st Report :
30 days from review
Response from
Department
head(s):
Subsequent
Report(s):
30 days from receipt of 1st report


Project Lead produces written report
Identify all legal (state and federal) compliance
problems
Identify all environmental, health and safety issues
that are not in compliance with Regents’ policy,
University, and/or specific program requirements
Other recommendations
Follow up reports continue every
30 days until all corrective
actions are addressed
REPORT DISTRIBUTION:




Manager responsible for the area under assessment
MAU EHS Director
SW EHS Representative
Intelex database (report copy as well as for on-going management of non-compliance items, if any)
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LEVEL THREE GAP ANALYSIS
PROJECT LEAD: As determined by MAU
DESCRIPTION:
A Level Three Gap Analysis is an assessment conducted by a smaller focus group and usually does not include an
EHS professional. Examples would be peer inspections of department level safety committees or voluntary
program compliance assessments conducted by programs or departments to assess overall compliance status.
REPORTING FORMAT:
REPORTING TIME FRAME:


1st Report :
30 days from review
Response from
Department
head(s):
Subsequent
Report(s):
30 days from receipt of 1st report


Project Lead produces written report
Identify all legal (state and federal) compliance
problems
Identify all environmental, health and safety issues
that are not in compliance with Regents’ policy,
University, and/or specific program requirements
Other recommendations
Follow up reports continue every
30 days until all corrective
actions are addressed
REPORT DISTRIBUTION:



MAU EHS Director
SW EHS Representative
Intelex database (report copy as well as for on-going management of non-compliance items, if any)
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LEVEL FOUR GAP ANALYSIS
PROJECT LEAD: SW EHS Director or designee
DESCRIPTION:
A Level Four assessment may be a review of a Campus or SW program or department. The scope can range from
a full-scale team effort to a small individual focused review. A brief opening conference will kick off the
beginning of each Level Four Gap Analysis to explain to managers and staff the objectives of the analysis. A
document review, employee interviews and site visit will follow the opening conference. A verbal summary of
the conditions found will be discussed at a closing conference.
REPORTING FORMAT:
REPORTING TIME FRAME:

1st Report :
30 days from closing conference
Response from
Department head:
Subsequent
Report(s):
30 days from receipt of 1st report



Project Lead produces written report with executive
summary to department head (See Attachment 1 for
Gap Analysis Check List.)
Identify all legal (state and federal) compliance
problems
Identify all environmental, health and safety issues
that are not in compliance with Regents’ policy,
University, and/or specific program requirements
Other recommendations
Follow up reports continue every
30 days until all corrective
actions are addressed
REPORT DISTRIBUTION:







Manager responsible for the area under assessment
Executive level department director
Vice Chancellor for Administration (for Campus reviews)
Vice President for Finance (for SW reviews)
MAU EHS Director
SW EHS Representative
Intelex database (report copy as well as for on-going management of non-compliance items, if any)
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ATTACHMENT 1
LEVEL ONE AND FOUR GAP ANALYSIS CHECK LIST
PROJECT DESCRIPTION:
CAMPUS:
DATE:
GAP ANALYSIS LEVEL (circle one):
ONE
FOUR
PROJECT LEAD NAME:
TITLE:
Following are the minimum requirements for review and reporting in a Level One or Four Gap Analysis:
Location and specific area investigated
Names of personnel the team has discussions with and concerns voiced
Method of communication(s) of work hazards to personnel
Survey condition of tools and equipment
Specific work procedures reviewed
Documentation reviewed and condition of the documentation (previous audits, inspections or investigations,
hazard analysis, regulatory programs, regulatory training and/or standard operating procedures)
Energy sources present, barriers in place and practices utilized
Personal protective equipment availability, condition, and use
Noise, air, workspace, and lighting conditions
Chemicals available to personnel, the use and control of those chemicals
Environmental practices i.e. waste management and protection of water drainage
Personnel training practices
Radiation sources identified and handling methods
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