2015 Safety Group Audit Report

WorkWell Criteria

Firm Information:

All information below must be completed.

Name of Firm:
If this audit report covers more than one location findings, please list all locations to whom this audit applies:
Can provide on a separate sheet, with account and firm numbers
WSIB Account Number(s):
WSIB Firm Number(s):
Auditor Name(s):
Did the auditor(s) complete the WSIB Introduction to Auditing Course in 2015?
Date Audit Commenced:
Date Audit Completed:
Date Audit findings were reviewed by the Auditor with Senior Manager:
Senior Manager Name:
Date Senior Manager finished their review of Audit:
Date Senior Manager finished their review of the Action Plan:
Person Responsible for recording resolution of non-conformity action items:
This page is documentation of the required reviews for the WSIB Safety Groups Advantage Program 2015. This is the electronic verification of names and signatures:
Name of Auditor (lead if more than one):
Position in your firm:
Contact Phone Number:
Name of Senior Manager who reviewed the Audit and Action Plan (list all, if more than one):
Title:
Phone Number:

How to use this Form

The 12 sections of WorkWell have been broken out. The Auditor completes all columns in all 12 sections up to the decision of “Conformity”. The Senior Manager completes the review of the audit and the action plan.

Timelines for 2015

The audit must be completed and sent to Dunk & Associates by September 1st 2015.

The Senior Management sign-off, determination of action items and assigned responsibility with timelines must be

completed prior to submission to Dunk by September 1st 2015.

1

WorkWell Section 1
WorkWell Section / Criteria / Step 1: Standard Criteria (Every box must be checked for your standard to meet conformity and must be dated the last 12 months / Step 2: List additional evidence (proof) that your company is implementing what you stated in your written standard. (You must list sufficient additional corroborating evidence (records, observations, and interviews) to select a finding of conformity. If you're unable to verify additional evidence, briefly list what you could not verify, and select finding of non-conformity.) / Decision: Conformity or Non-Conformity and Senior Management Review
(You must be in conformity for both Step 1 & 2 to have conformity) / Action Plan, Assignment and Timframe: What action items are required for non-conformities? List what will be done. (All missing criteria from Step One and Step Two must be included in the Action Plan.) / Confirmation of Action Plan completed/Date
1.1 / Health and Safety Policy Containing the following:
(1.1a-g) / Does this Policy Exist?
Yes
Title of Policy
Dated:
1.1a / Employer Commitment / A statement of commitment to preventing occupational illness and injury in the workplace / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
1.1b / Employer Responsibilities / A statement of commitment to implement and maintain a safe and healthy work environment / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
1.1c / Supervisor Responsibilities / A statement of responsibility to ensure that safe and healthy work conditions are maintained in his/her assigned work area / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
1.1d / Worker Responsibilities / A statement of responsibility to work in accordance with legislated standards and employer Safe Work Procedures/Practices / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
1.1e / Dated / The posted copy is dated within a 12 month period / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
1.1f / Signed / The posted copy is signed by the most senior management person on site / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
1.1g / Posted / Posted in a high traffic area
Accessible to all workers / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
1.2 / Workplace Violence & Harassment Policy
(This may be part of your H&S policy) / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Signed by the most senior management person
Dated in the last 12 months
Posted in a high traffic area / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
Comments:
WorkWell Section 2
WorkWell Section / Criteria / Step 1: Standard Criteria (Every box must be checked for your standard to meet conformity and must be dated the last 12 months / Step 2: List additional evidence (proof) that your company is implementing what you stated in your written standard. (You must list sufficient additional corroborating evidence (records, observations, and interviews) to select a finding of conformity. If you're unable to verify additional evidence, briefly list what you could not verify, and select finding of non-conformity.) / Decision: Conformity or Non-Conformity and Senior Management Review
(You must be in conformity for both Step 1 & 2 to have conformity) / Action Plan, Assignment and Timframe: What action items are required for non-conformities? List what will be done. (All missing criteria from Step One and Step Two must be included in the Action Plan.) / Confirmation of Action Plan completed/
Date
2.1 / Health and Safety Responsibilities Policy includes the following:
2.1a / Manager Responsibilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Workplace inspections
Information Sessions
Incident Investigations
Worker Training
Correcting substandard acts or conditions
Commending Worker H&S performance
Appoint a competent supervisor
Section 25 & 26 of the OHSA / Record
Interview
Observation / Conformity
Non-Conformity
Non Applicable
(N/A only if you do not have managers)
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.1b / Manager Accountabilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Who conducts the evaluation
Measures each responsibility in section 2.1a
Completed at least annually / Record
Interview
Observation / Conformity
Non-Conformity
Non Applicable
(N/A only if you do not have managers)
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.1c / Supervisor Responsibilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Workplace inspections
Information Sessions
Incident Investigations
Worker Training
Correcting substandard acts or conditions
Commending Worker H&S performance
Section 27 of the OHSA / Record
Interview
Observation / Conformity
Non-Conformity
Non Applicable
(N/A only if you do not have supervisors)
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.1d / Supervisor Accountabilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Who conducts the evaluation
Measures each responsibility in section 2.1c
Performed at least annually / Record
Interview
Observation / Conformity
Non-Conformity
Non Applicable
(N/A only if you do not have supervisors)
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.1e / Worker and Supplied Labour Responsibilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
H&S rules for the workplace
Included section 28 of the OHSA / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.1f / Worker and Supplied Labour Accountabilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
A formalized performance review
Progressive discipline process
Worker understands the consequences of H&S violations / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.1g / Contractor Responsibilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Ensure H&S of workers
Provide qualified workers
Ensure they work within governing legislation/regulations/industry standards
Communication of workplace specific H&S rules and Emergency Procedures / Record
Interview
Observation / Conformity
Non-Conformity
Non Applicable
(N/A only if you so not have contractors)
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.1h / Contractor Accountabilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Performance Review
Consequences of unsafe behavior, policy or procedure violation / Record
Interview
Observation / Conformity
Non-Conformity
Non Applicable
(N/A only if you so not have contractors)
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.1i / Visitor Responsibilities / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
H&S rules for the workplace to read before entering the workplace
Escorted while in the workplace
Use of PPE
Remain in designated areas
Report injury/illness suffered / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.2 / The employer has designated an individual, who has the knowledge and experience to co-ordinate the worksite health and safety activities:
2.2a / The employer has assigned an individual to coordinate the health and safety activities. / A written description for this individual, outlining specific activities to coordinate the health and safety program
Title of the Document
Dated: / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
2.2b / The individual is experienced and trained. / The individual has industry Experience and knowledge of the following fields:
Applicable safety legislation
Incident investigation
Workplace inspection / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
Comments:
WorkWell Section 3
WorkWell Section / Criteria / Step 1: Standard Criteria (Every box must be checked for your standard to meet conformity and must be dated the last 12 months / Step 2: List additional evidence (proof) that your company is implementing what you stated in your written standard. (You must list sufficient additional corroborating evidence (records, observations, and interviews) to select a finding of conformity. If you're unable to verify additional evidence, briefly list what you could not verify, and select finding of non-conformity.) / Decision: Conformity or Non-Conformity and Senior Management Review
(You must be in conformity for both Step 1 & 2 to have conformity) / Action Plan, Assignment and Timframe: What action items are required for non-conformities? List what will be done. (All missing criteria from Step One and Step Two must be included in the Action Plan.) / Confirmation of Action Plan completed/
Date
3.1 / Policy on Posted Materials / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
A list of posted materials required for your workplace
How frequently the posting need to be updated/replaced
Where to post materials / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1a / Occupational Health & Safety Act (OHSA) / Posted in a high traffic area
Accessible to all workers / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1b / Appropriate Regulations / Posted in a high traffic area
Accessible to all workers / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1c / WHMIS Regulations / Posted in a high traffic area
Accessible to all workers / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1d / Material Safety Data Sheets / Posted in a high traffic area
Accessible to all workers / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1e / Designated Substance Regulation / Posted in a high traffic area
Accessible to all workers / Record
Interview
Observation / Conformity
Non-Conformity
Non Applicable
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1f / Health & Safety Explanatory Materials (Gide to the OHSA) / Posted in a high traffic area
Accessible to all workers / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1g / Form 82 – In Case of Injury at Work Poster / Posted in a high traffic area
Available at all First Aid stations / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1h / First Aid Regulation 101 / Posted in a high traffic area
Available at all First Aid stations / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1i / Emergency Services and Phone Numbers / Posted at primary telephones throughout the facility (including offices)
Emergency #'s Include:
911
Fire
Police
Ambulance
Ministry of Labour
Ministry of Environment
Utilities
Internal Contacts / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1j / Reports / Posted in a high traffic area
Accessible to all workers
Reports include:
Monthly Workplace Inspections
JHSC Meeting Minutes
H&S assessments/surveys
Ministry of Labour Orders / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
3.1k / Other / Available as applicable to the worksite activities
May Include:
Traffic Control
Transportation of Dangerous Goods / Record
Interview
Observation / Conformity
Non-Conformity
Non Applicable
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
Comments:
WorkWell Section 4
WorkWell Section / Criteria / Step 1: Standard Criteria (Every box must be checked for your standard to meet conformity and must be dated the last 12 months / Step 2: List additional evidence (proof) that your company is implementing what you stated in your written standard. (You must list sufficient additional corroborating evidence (records, observations, and interviews) to select a finding of conformity. If you're unable to verify additional evidence, briefly list what you could not verify, and select finding of non-conformity.) / Decision: Conformity or Non-Conformity and Senior Management Review
(You must be in conformity for both Step 1 & 2 to have conformity) / Action Plan, Assignment and Timframe: What action items are required for non-conformities? List what will be done. (All missing criteria from Step One and Step Two must be included in the Action Plan.) / Confirmation of Action Plan completed/
Date
4.1 / Employer has identified H&S Hazards, implemented controls, and developed safe operating procedures where necessary:
4.1a / Identify all health and safety hazards in the workplace / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
A list of activities performed by the workers
Implement a review process / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
4.1b / Rate each hazard for loss potential and implement health and safety controls / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Rate hazards for loss potential
Identify controls in place for the hazards identified
Consider controls according to the following priority
•Elimination
• Substitution
•Engineering controls
•Administrative controls
•PPE / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
4.1c / Develop and implement safe operating procedures (SOP's) /safe work instructions for every activity rated as a major hazard / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Developing a step-by-step description for each activity rated as a major hazard
H&S controls at each step
Inform and instruct all workers of the SOP's / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
4.2 / The employer has developed and implemented standards and procedures for:
4.2a / Injury/Illness Reporting / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Definition of injury/illness
When to report
How to report (form)
Who should be notified
What treatment will be provided
Recording requirements
Follow-up contacts / Record
Interview
Observation / Conformity
Non-Conformity
Senior Management Review
Agree
Disagree / Action Plan:
Action Items Assigned to:
Timeframe for Completion:
4.2b / Hazard Reporting / Does this Policy Exist?
Yes
Title of Policy
Dated:
Policy Includes:
Definition of hazardous condition/act
When to report