SAT TOOL – School response
Document number: [Insert local area document number]
Prepared on: [INSERT DATE]
Submitted on-line on: [INSERT DATE]
Issue # 000[INSERT NUMBER]
Discussed at L3 H&S consultation committee on: [INSERT DATE]
#
Crit
No.
1.
1.1.2
2.
2.1.3
3.
2.1.1
4.
2.1.5
5.
2.2.1
Examples of evidence
Audit Question
Is the UNSW OHS Policy
displayed in a prominent
position in the workplace?
Do relevant people have ready
access to current OHS
legislation and standards?
 An electronic copy of policy is on
OHS Unit website
 Policy included in induction
material
 Policy included in tender
documentation (ie.
communication to contractors)
 Policy is displayed in
reception/visitor areas
 Access to legislation under “Web
Links” on the OHS Unit website
Is there a mechanism to
communicate changes to
legislation, standards and
University procedures to
relevant people?
 OHS Committee Reps receive
monthly OHS Coordinator’s
report
 OHS Committee meeting minutes
 Emails
Does notification of changes to
legislation or standards prompt
a review of relevant risk
assessments/protocols/safe
work procedures?
Are you aware of any health
and safety targets and
objectives set by UNSW Level
1 OHS committee?
 Reviewed risk assessments/Safe
Work Procedures (SWPs)
 Emails
Page 1 of 23
 Current OHS Strategic Plan
 UNSW OHS Measures and KPTs
for Managers
 L2 OHS Committee minutes
Response evidence
Corrective Action Required
#
Crit
No.
6.
2.2.2
7.
2.2.3
&
2.3.3
&
3.6.4
8.
3.1.1
&3.1.
2
9.
3.1.3
10. T 3.2.1
r
a
Examples of evidence
Audit Question
Does the Faculty document
OHS objectives, or is OHS
included in key performance
targets for senior managers
(e.g. Head of School/Dept)?
Are there tools/mechanisms in
place for monitoring progress
towards meeting the OHS
objectives and targets in your
work area?
 Faculty/Division operational plans
include OHS objectives
 Senior Managers have OHS
objectives included in their KPTs
Have financial and physical
resources been identified,
allocated and periodically
reviewed, to enable the
effective implementation of
UNSW’s health and safety
management system?
 Budget provided for OHS
 Budget to allow risks to be
controlled by engineering means
 Funding to allow equipment to be
upgraded/replaced as required
 Competent personnel allocated to
ensure implementation of system
e.g. Staff to provide training on
equipment, maintain OHS
documentation, OHS Reps.
OHS Reps are allocated time to:
Are OHS representatives
(committee members) provided
with time and resources to
effectively undertake this role?
Can senior management
demonstrate an understanding
of UNSW’s legal obligations for
Page 2 of 23
Quarterly review of OHS statistics
at OHS Committee meetings,
including for example:
 % of staff who have completed
OHS induction
 % of staff who have completed
OHS awareness training
 % of corrective actions closed
 Injury statistics
 Completion of Self Audit Tool
(SAT) by local area annually
 attend OHS training,
 prepare for & attend OHS
meetings,
 conduct workplace inspections,
 attend incident investigations
 Head of School/Department
Manager has attended OHS Due
Diligence or OHS for Supervisors
Response evidence
Corrective Action Required
i
n
11.
3.2.3
PI
12.
Examples of evidence
Crit
No.
#
3.2.5
Audit Question
health and safety? E.g.
Attendance at Due Diligence
or OHS for Supervisors
training?
Have OHS responsibilities
been assigned and
communicated to all staff? E.g.
Maintaining registers, closing
corrective actions, training,
inspection and testing of
equipment, keeping records.
Is OHS performance included
in staff performance reviews?
PI
13. c 3.2.4
o
n
t
r
a
c
t
o
r
s
14.
3.2.4
training
OHS responsibilities may be
included in:
 Position descriptions
 OHS 336 Responsibility
Procedure
 Laboratory Manuals
 Performance Development
Scheme (PDS)
 If OHS tasks have been
assigned, the completion of such
tasks are monitored through the
annual performance appraisal
conducted by the supervisor or
other mechanisms e.g. Monthly
meetings
Does your area engage
contractors directly? (i.e. not
via Facilities Management)
NOTE: If they answer “NO”
then they do not need to
complete Qs 14, 15 & 16.
Where contractors are
engaged, are the OHS
responsibilities for both the
contractor and the University
clearly defined, allocated and
Page 3 of 23
 Documented OHS responsibilities
for both parties e.g. contractual
agreements
 Induction program for contractors
covering responsibilities and
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
Audit Question
communicated?
accountabilities
 Checks include evidence of:
- Workers Compensation
insurance
- Public liability insurance
Is an assessment conducted of
the ability of contractors to
meet health and safety
requirements prior to engaging
the contractor?
15.
3.10.3
16.
3.10.4
17.
3.5.3
18.
3.2.4
Is an OHS Induction provided
to all contractors?
 Assessment is conducted for
UNSW preferred suppliers
 Health & safety requirements
(including evidence of workers
compensation and public liability
insurance) are stated in
contractual documents, where
local area engages contractor
 Periodic audits are conducted
 Progress meetings with
contractor include OHS issues
 Records of observation of
contractor performance (e.g.
Diary entries)
 Correspondence with contractors
about issues of non-compliance
 OHS induction for
contractors/visitors
 Minutes of meetings with
contractor, suppliers, authorities
etc which record discussion of
OHS issues
 Equipment manuals from
suppliers
 Safety Data Sheets for any
chemical used by contractors
 Completed contractor induction
checklists for local area
19.
3.4.2
Has the work area determined
the number of employee
 OHS634 OHS Committee
Constitution document has been
Is contractor health and safety
performance monitored and
reviewed to ensure continued
adherence to UNSW health
and safety requirements or
specifications?
Is relevant health and safety
information exchanged
between local area and
external parties including
customers, suppliers,
contractors and relevant public
authorities?
Page 4 of 23
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
20.
3.4.3
21.
3.3.9
22.
3.4.4
23.
3.4.6
24.
3.9.7
Audit Question
representatives required to
effectively represent all
employee work groups?
completed and is up to date
 Minutes of meetings that record
discussion regarding appropriate
number of employee vs employer
reps
Are employees involved in the
selection process for their OHS
representatives?
Examples may include:
 Emails requesting nominations
for OHS Reps
 Minutes of OHS Committee
meetings
Have all OHS Reps. and
members of OHS committees
received OHS consultation
training?
Have the names and identities
of the work area’s employee
and employer OHS
representatives been
communicated to all staff?
 Records of attendance at OHS
Consultation training
Does staff get informed about
changes to their work
processes and environment so
they can be consulted on the
OHS risks of such changes, if
applicable?
 Committee minutes
 Staff meetings
 Emails
Are risk assessments
undertaken for changes in the
workplace which may affect
health and safety (if
applicable)?
 Completed risk assessments if
local area has undergone change
in the workplace
Page 5 of 23
 Emails
 Committee minutes
 Local area website
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
25.
3.4.7
26.
3.4.7
27.
3.5.2
28.
3.3.8
PI
29.
3.6.1
30.
3.7.1
PI
Audit Question
Are OHS Committee meetings
held at least quarterly?
 L3 OHS Committee constitution
which specifies frequency of
meetings
 OHS Committee meeting minutes
Are minutes of OHS meetings
made available to all
personnel?
 Minutes of OHS Committee
meetings are distributed via email
and/or posted on staff
noticeboards
 Minutes posted on local area
website
Is there a feedback
mechanism to report progress
on OHS issues (or resolution
of OHS disputes)?
 Online hazard & incident
reporting system
 Emails
 Minutes from OHS Committee
meetings
Have all supervisors and
managers completed “OHS for
supervisors” training?
 Training attendance records
Are staff notified about the
procedure for reporting
hazards and incidents in the
workplace?
 OHS Induction records which
document that Hazard & Incident
reporting procedure is covered
during Induction
 Links to the OHS website is
included on local area website
Are local OHS procedures
(e.g. SWPs) easily identifiable,
accessible and included on a
documents register?
 Document control is included on
local procedures including SWPs
 Local procedures are available
on school/unit website
 Completed OHS document
register
Page 6 of 23
Response evidence
Corrective Action Required
#
31.
3.8.1
&3.8.
2
32.
3.8.3
PI
33.
Examples of evidence
Crit
No.
3.8.4
PI
34.
3.10.2
35.
3.10.5
PI
Audit Question
Is there a system for creating,
modifying and approving local
area health and safety
documents, and notifying
relevant persons of any
changes?
Are health and safety
documents readily accessible
to users?
Do local OHS documents get
reviewed by competent
persons to ensure the
adequacy and currency of the
information?
Are health and safety
requirements documented and
incorporated into purchasing
specifications for services?
Are health and safety
requirements considered prior
to the purchase of goods? e.g.
impact on the workplace,
additional training
requirements etc.
Page 7 of 23
 Examples of local area
procedures
 Examples of updated versions of
procedures following review,
including version number and
review date
 Emails to staff notifying them of
new/revised OHS procedures
 University OHS procedures are
available on UNSW OHS website
 Local OHS documents are
available on school/unit website
or in hard copy within local area
 Local OHS documents including
risk assessments and SWPs are
reviewed and signed off by
appropriate and competent
Supervisor
 UNSW preferred suppliers are
used
 Staff follow UNSW Tender
Procedure for purchases where
“no UNSW preferred supplier”
exists
 Local area has evidence that
OHS requirements are
communicated to the contractor
prior to engagement
 Completed OHS0633 Pre/Post
Purchasing Checklist
Response evidence
Corrective Action Required
#
36.
3.10.6
PI
37.
3.11.8
38.
2.3.2
39.
3.9.1
&
3.9.3
PI
40.
3.9.1
PI
41.
3.9.2
PI
42.
Examples of evidence
Crit
No.
3.9.4
&
2.1.2
Audit Question
Are purchased goods checked
for compliance with
specifications prior to being put
into use?
Have all staff been informed
about the Employee
Assistance Program (EAP) for
dealing with exposure to
critical incidents at work?
Does the local area follow the
UNSW procedures for
conducting risk assessments?
Has your local area
systematically identified and
documented its hazards and
risks and implemented control
measures according to the
hierarchy of risk control?
Do risk assessments take into
account the risks involved in
working after hours and/or
working alone?
 Completed OHS0633 Pre/Post
Purchasing Checklist
 EAP Information included in HR
Induction
 EAP info included on local area
website
 EAP phone number displayed on
staff noticeboards
 Completed risk assessments
 Completion of online hazard and
incident reports
 Local area Hazard & Risk
Register
 Completed risk assessments for
tasks/ projects/activities that pose
OHS risks including work with
chemicals, biological or infectious
materials, radiation devices
/radioactive substances, manual
handling tasks, plant and
equipment etc.
 Risks involved in working after
hours and/or working alone are
included in Risk Assessments
and Hazard & Risk Register
Have all personnel who
undertake risk assessment
completed OHS Awareness
training or equivalent?
 Training attendance records
Do risk assessments take into
account legal requirements or
any other available
information, past incidents,
 Completed risk assessments
showing reference to relevant
legislation, standards or codes of
practice
Page 8 of 23
Response evidence
Corrective Action Required
#
PI
43.
3.9.5
PI
44.
Examples of evidence
Crit
No.
3.7.2
PI
45.
3.10.1
46.
OUR
S
Audit Question
and potential for emergency
situations?
Is the timing of corrective
actions done in accordance
with the timeframes set for the
risk rating?
 Action to be taken in the event of
an emergency addressed in risk
assessment
 Corrective action is completed
within timeframes set by risk
rating from the online reporting
system
Have safe work procedures
been developed to address
specific risks? (e.g. hazardous
substances, biological
hazards, radioactive
substances etc)
 Completed Safe Work
Procedures for tasks/
projects/activities that pose OHS
risks including work with
chemicals, biological or infectious
materials, radiation devices
/radioactive substances, manual
handling tasks, plant and
equipment etc.
Have those areas where
access control is required,
been documented and are
procedures in place to enforce
access requirements?
Are ergonomic workstation
assessments (peer or self
assessments) carried out for
office based staff?
 Swipe card access
 Authorised key holders
 Documented procedures for
access
Is appropriate manual handling
equipment available where
required, and have staff been
trained in its use?
 Completed manual handling risk
assessments identify the need for
manual handling equipment
 Visual assessment of equipment
Is a risk assessment
undertaken during equipment
or building modification,
 Completed risk assessments
 Evidence that health & safety
considerations are examined
 Completed workstation
assessment checklists
PI
47.
OUR
S
PI
48.
3.10.7
Page 9 of 23
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
Audit Question
refurbishment or design?
49.
3.10.8
50.
3.10.9
PI
51.
3.10.1
1
PI
52.
3.10.1
2
PI
53.
3.10.1
3
prior to installation of new
equipment
Are competent personnel
involved in verifying that the
designs and modifications to
equipment meet specified
health and safety
requirements?
Are all hazardous materials
and substances disposed of in
accordance with OHS321
Hazardous Waste Disposal
Guideline? (E.g. chemical,
biological, animal carcass,
decayed radioactive waste
etc).
Are there safe work
procedures for the handling,
transfer and transport of
hazardous substances and
dangerous goods?
 Evidence that competent people
have involved in the designs and
modifications to equipment e.g.
relevant licences or accreditation
etc.
Is comprehensive health and
safety information on all
hazardous substances and
dangerous goods readily
accessible?
 Access to UNSW OHS website
 Compliant labels on all containers
 Access to ChemAlert
 Safety Data Sheets are available
Are hazardous substances and
dangerous goods safely stored
according to the Safety Data
Sheet?
 Compliant dangerous goods
storage facilities
 Self audits of chemical storage
 Compliant chemical labelling
If applicable, are there ‘Permit
to Work’ procedures for highrisk tasks e.g. confined space
 Completed permits
 Completed waste request forms
 Review of waste storage facilities
 Completed SWPs are available
PI
54.
3.10.1
4
Page 10 of 23
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
Audit Question
or hot work?
55.
3.10.1
7
Are staff aware of the process
to remove/quarantine unsafe
plant and equipment?
 Examples of equipment being
“locked out” with “danger tags” or
“out of service tag” in use.
 Laboratory induction
Are appropriate controls used
to ensure the safety of persons
working on or near plant and
equipment that is in the
process of being cleaned,
serviced, repaired or altered?
 Isolation and lockout
requirements in OHS327 Plant
and Equipment Procedure is
followed for maintenance or
cleaning activities where deenergising is required
 Evidence of completed “Out of
service” or “Danger” tags that
have been used on equipment
 Service records show competent
person checks that plant is safe
to use after repairs or
maintenance
PI
56.
3.10.1
8
PI
57.
3.10.1
9
58.
3.10.2
1
59.
3.10.2
5
Do competent personnel verify
that plant and equipment is
safe to use before being
returned to service after repair
or alteration?
If applicable, are there
procedures to ensure that
materials are transported,
handled and stored in a safe
manner? (NOTE: This relates
to general
storeroom/warehouse facilities
as opposed to dangerous
goods storage)
Do samples and materials
provided for diagnostic or
testing purposes undergo risk
assessment prior to use?
PI
Page 11 of 23
 Local area is following OHS709
Materials Handling Guideline if
applicable
 Safe Work Procedures are
available if required
 Procedures are in place to
protect persons receiving or
working on samples or materials
that are provided for diagnostic or
testing purposes
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
60.
3.10.2
6
61.
3.11.6
PI
62.
3.11.6
63.
OUR
S
64.
2.1.4
PI
Audit Question
Are all substances in
containers and transfer
systems identified and clearly
labelled to avoid inadvertent or
inappropriate use?
Is a chemical register available
that includes details of all
dangerous goods and
hazardous substances present
in the workplace?
If applicable, are your
dangerous goods storage
areas included in the
dangerous goods manifest for
your building?
Is the management of your
specific hazards being
monitored against the relevant
systems audit checklist e.g.
chemical system audit
checklist, bio-safety audit
checklist etc.
If applicable, does the work
area satisfy legal requirements
to undertake specific activities,
perform work or operate
equipment including:
(a) Any licence required?–
e.g. Licences or
approvals for certain
processes such as
asbestos removal, use
of carcinogens,
radioactive sources and
lead;
(b) Any Certificate of
competency required?
(c) Is notification to a
Page 12 of 23
 Substances are properly labelled
according to OHS429 Labelling of
Hazardous Substances
 Up to date chemical register is in
place
 Completed dangerous goods
manifest as per OHS333
Dangerous Goods Placard &
Manifest Procedure
 Completed audits/checklists for
Biological hazards, Chemical
Hazards, radiation.
 Radiation users licence
 Forklift licence
 AQIS approved premises
 Workcover approval for
prohibited or notifiable
carcinogens
 PC2 certification for laboratories
working with genetically modified
organisms
Response evidence
Corrective Action Required
#
3.3
65.
3.3.1
PI
66.
Examples of evidence
Crit
No.
3.3.2
PI
Audit Question
regulator required?
(d) Is registration of
equipment/premises
required? (e.g.
radiation or AQIS
premises)?
(e) Is there approval,
exemption
requirements?
Training and Competency
Have jobs which require the
incumbent to have specific
skills/competencies and/or
specific medical requirements
to perform that job safely been
identified? Have these
requirements been included in
job descriptions and job ads?
 Pre-employment health screening
is conducted for staff working
with animals
 Job ads specify licence or
certification requirements if
applicable e.g. Electrician or
forklift operator
 Job descriptions identify specific
skills/competencies or specific
medical requirements that are
required to perform the job safely
Has the training needs of staff
(visitor & contractors as
relevant) been identified
according to the work they will
be doing, location of the work,
previous training and
competency e.g. general OHS
awareness, work with
infectious materials, chemicals,
radiation, ergonomic, manual
handling etc.
 Generic Training needs are
identified as per OHS 320 OHS
Training and Induction procedure,
including Table 1 and 2 for
mandatory OHS training required
to satisfy certain competencies
 Local training needs analysis
identifies competencies to
operate pieces of equipment
 Evidence that staff have been
trained & are competent in SWPs
for equipment
Page 13 of 23
Response evidence
Corrective Action Required
#
67.
3.3.3
PI
68.
3.3.5
PI
69.
3.3.6
PI
70.
Examples of evidence
Crit
No.
3.3.7
Audit Question
Are all personnel appropriately
inducted into the workplace
according to their level of risk
exposure?
 Completed inductions
After staff, contractors and
labour hire employees have
completed training, does the
work area assess the
individual’s ability to apply the
knowledge/skills learnt during
the training, in order to perform
the job safely? (ie.
Competency based training)
 Training records
 Training assessment/test after
completing training courses
 Training in an SWP with
demonstrated ability
that it can be followed
accurately.(e.g. checklist)
Is training and assessment
delivered by persons with
appropriate knowledge, skills
and experience?
 Local training is delivered by
competent people as identified on
the SWP
Are tasks allocated to match
the skills, training and
capabilities of employees?
 Evidence that job application
addresses the selection criteria in
the job advertisement
 Competency to perform specific
tasks is confirmed before
allocation of tasks
Is OHS refresher training
undertaken as required?
 Training plan includes provision
for refresher training
 The nominal refresher period
identified in UNSW’s OHS320
OHS Training Procedure are
used as a guide
 Evidence that training materials
are reviewed and updated
PI
71.
3.3.10
PI
72.
3.3.11
PI
Is the training provided by the
local area reviewed on a
regular basis, and when there
are changes to plant or
processes in the workplace?
Page 14 of 23
Response evidence
Corrective Action Required
#
73.
3.10.1
0
74.
3.10.1
5
PI
75.
3.10.2
0
76.
3.10.2
2
PI
77.
Examples of evidence
Crit
No.
3.10.2
3
Audit Question
Are facilities and amenities
checked against the
requirements of relevant
legislation, standards and
codes of practice?
 Completed Workplace
Inspections
Is the Personal Protective
Equipment (PPE) provided
appropriate for the task, are
people trained in its use, is it
used correctly and is it
maintained in a serviceable
condition?
 Safe Work Procedures specify
any relevant PPE that must be
worn
 Observations of staff using PPE
during workplace inspections
Do safety signs meet relevant
standards and are they
appropriately displayed?
 Safety signs conform with
OHS732 Signage Guideline
Are individuals supervised
according to their capabilities
and the degree of risk of the
task?
 SWP’s specify the level of
supervision required
Are supervisors monitoring that
tasks are performed safely and
work instructions and
procedures are followed?
 Local organisational charts
showing reporting lines
 Completed OHS729 Laboratory
Review Forms
 Training records for attendance
at OHS for Supervisors course
 Performance appraisals for
Supervisors
 Potential emergencies within
local area have been identified
 If required, local site procedures
have been developed to identify
actions to be taken for specific
emergencies e.g. isolating a gas
valve before evacuation or
PI
78.
3.11.1
Have potential emergency
situations been identified and
emergency procedures
documented and regularly
reviewed?
Page 15 of 23
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
Audit Question
shutting off heat or ignition
sources.
79.
3.11.2
&
3.11.7
80.
3.11.3
81.
3.11.4
82.
3.11.4
Has the area allocated
responsibility for control of
emergency situations
(including appropriate number
of First Aid Officers) to
specified individuals and
communicated this information
to all personnel?
 Documented assessment of
Emergency personnel needs with
respect to numbers and size of
work area, risk level, proximity to
hospital or UNSW health service
etc.
Have emergency response
personnel received appropriate
training for their duties?
Have competent persons
assessed the suitability,
location and accessibility of
emergency equipment that is
not being centrally maintained
by Facilities? (e.g. First Aid
Kits, Spill Kits, Emergency
showers)
 Training records
Are the following emergency
resources available as
applicable?
 First Aid Kits
 Spill kits capable of
 First Aid Kits are easily
accessible to staff
 Spill kits are available, with
appropriate contents to match the
needs of the area
Page 16 of 23
 A documented emergency plan
with details of responsibilities for
Fire Wardens, Emergency
Controllers and First Aid Officers
 Induction process that includes
introducing employees to local
fire wardens etc.
 Training records for attendance
at First Aid/Fire Warden training
 Spill kits are available, with
appropriate contents to match the
needs of the area
 Checks that emergency showers
and/or eyewash stations are
operating and maintained
Response evidence
Corrective Action Required
#
83.
3.6.3
84.
3.6.5
85.
3.10.1
6
PI
86.
Examples of evidence
Crit
No.
3.10.1
6
Audit Question
being able to handle
the largest size
containers
 Suitable PPE in the
spill kit such as
reusable gloves,
goggles, respirators
and cartridges, gum
boots etc as
appropriate
Are inspection, testing and
monitoring reports
communicated to Head of
School/Work Unit (and
committee representatives)?
Are OHS audit reports
distributed within your area?
Is there a local inspection,
testing and monitoring
schedule for plant and
equipment and maintenance
records kept?
Is electrical testing & tagging
conducted in the local area at
the required frequency based
on the risk?
Page 17 of 23
 Committee minutes table
outcomes of workplace
inspections/electrical testing &
tagging reports etc., where Head
of School/Unit (or their nominated
representative) is present
 Minutes of meeting reflect that
progress of corrective actions is
monitored
 Email distribution of audit reports
 Audit report findings
communicated at OHS
Committee meetings
 Completed Plant Register/
Inspection, Testing and Monitor
schedule
 Maintenance records
 Electrical testing & tagging
records
 Current tags on equipment
Response evidence
Corrective Action Required
#
87.
4.1.1
88.
4.1.1
89.
4.1.2
90.
4.1.3
PI
91.
Examples of evidence
Crit
No.
4.1.4
Audit Question
Do local area workplace
inspections occur using
appropriate checklists?
 Completed workplace inspection
checklists
 Records of other workplace
inspections e.g. PC2 inspections,
Chemical audit.
 Completed lab/workshop review
forms to monitor conformance
with SWP and measure
effectiveness of risk controls
Are corrective actions
identified during workplace
inspections added to online
corrective actions register
through myUNSW?
Do inspections require the
involvement of personnel in
the area being inspected?
Are engineering controls,
including safety devices,
regularly inspected and tested
to ensure their integrity?
 Corrective actions arising from
inspections are entered into
online reporting system
Is monitoring of the workplace
environment (general and
personal for fumes, dust,
noise, radiation, etc.)
conducted where appropriate
and records of the results
maintained?
Page 18 of 23
 Verbal verification
 Plant is inspected in accordance
with Inspection, Testing &
Monitoring Schedule
 Maintenance records confirm
inspection of engineering controls
e.g. fixed guards & barriers,
emergency stop buttons
 Local area is familiar with
OHS091 Air Monitoring and
Health Surveillance Guideline
 Risk Assessments that identify
the need for workplace
monitoring for hazards such as
noise, fumes, gases, radiation,
are available
 Records of air monitoring
(including radiation swipe tests)
are available, if applicable
Response evidence
Corrective Action Required
#
92.
4.1.5
PI
93.
4.2.1
PI
94.
Examples of evidence
Crit
No.
4.3.1
Audit Question
Is inspection, measuring and
test equipment used for health
and safety monitoring
appropriately identified,
calibrated, maintained and
stored?
Has the area identified those
situations where employee
health surveillance should
occur and is a system
implemented to conduct this
surveillance?
 Records of calibration of
equipment
 Records of scheduled
maintenance
Are supervisors involved in
incident investigations?
 OHS307 Hazard and Incident
Reporting Procedure is followed
 Online hazard & incident form
has been completed, including
corrective actions
 OHS003 Incident Investigation
Guide is followed
 Completed investigation
documents which show the
involvement of line managers in
the process
 Interview notes from interviews
conducted with line managers
 Emails from line managers
Are personnel identified to
implement and review
corrective actions arising from
investigations?
Are corrective actions
discussed with personnel
 Corrective Actions register on
online system
 Identified in Investigation report
&
4.3.2
95.
4.3.3
96.
4.3.4
Page 19 of 23
 Risk assessments/incident
reports identify those situations
where employee health
surveillance is required
 Results of radiation personal
dose monitors
 Results of eye examinations for
exposure to lasers
Results of audiometric testing if
required
 Verbal verification
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
97.
4.4.1
98.
4.5.3
99.
OUR
S
Audit Question
affected prior to
implementation?
Are there effective systems in
place for the management of
OHS records including where
they are stored, who has
access, what’s confidential,
how long they are maintained,
how they will be disposed etc ?
Are non-conformances
identified during an OHS audit
prioritised and progressed until
action has been completed?
SPECIFIC QUESTIONS
RELATING TO BIOLOGICAL
AND RADIATION HAZARDS:
Is your work unit involved in
any activity that poses a
biological risk? If ‘No’ go to
question 104.
 Completed current local OHS
Records register in accordance
with OHS 733 Records
Procedure
 Non-conformances have been
entered and are tracked in
corrective actions register
n/a
PI
100. OUR
S
PI
101. OUR
S
PI
102. OUR
S
PI
Are you maintaining a
Biological Organisms
Register?
 Completed biological organisms
register using OHS075 Biological
Organisms template.
If applicable, is your PC2
containment facility registered
using the School containment
facility register?
 All PC2 containment facilities are
included on the OHS 078
Containment Facility register.
If applicable, is the location
where gene technology work
occurs monitored to ensure it
meets with the Gene
Technology Regulations and
has it being certified if
required?
 Annual inspections by the IBC
 Other completed inspections by
supervisors or OHS committee
Page 20 of 23
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
103. OUR
S
Audit Question
Are all dealing with genetically
modified organisms assessed
by UNSW IBC or the OGTR as
per Bio-safety Procedure?
 Completed records of research
projects having been assessed
by the IBC using OHS013 GMO application form
Has a Radiation Safety
Supervisor and TLD Badge
Coordinator been nominated to
facilitate communication on
radiation safety issues and
assist with implementation of
the Radiation Safety
Procedures?
 The role of Radiation safety
supervisor has been allocated in
the local area and responsibilities
documented.
Is a purchasing procedure for
the purchase of radioactive
isotopes implemented to avoid
the need for long term storage
of radiation waste?
 Purchasing for radioactive
isotopes is screened as per local
area purchasing system.
Are all staff using ionising
radiation who need licensing
appropriately licensed?
 Records show that all staff who
work with radioactive substances
or radiation devices are licensed.
Are licence exemption
procedures in place for
students?
 Evidence that students are
working under supervisor’s
licence.
Are all projects involving
radiation approved by the
UNSW Radiation Safety
Committee?
 Completed OHS695
Project/Program Approval Forms
for radiation work .
PI
104. OUR
S
PI
105. OUR
S
PI
106. OUR
S
PI
107. OUR
S
PI
108. OUR
S
PI
Page 21 of 23
Response evidence
Corrective Action Required
#
Examples of evidence
Crit
No.
109. OUR
S
Audit Question
Is all radiation waste requiring
storage adequately labelled
and stored in an appropriate
location?
 Physical evidence – labels on
containers, evidence of waste
transfer to radiation store.
Are all laboratories (premises)
using unsealed radioactive
materials exceeding prescribed
limits registered?
 Laboratories using licensable
quantities of unsealed radioactive
materials are registered.
PI
110. OUR
S
PI
Page 22 of 23
Response evidence
Corrective Action Required
ACTION SHEET
Q.
Issue
#
SAT
question
number
Issue
number
generat
ed by
online
hazard
reportin
g
system
Action
Corrective actions
Page 23 of 23
By Who
Date done