ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE:

Transcription

1 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: Table of Contents 1. Introduction 1.1 Introduction to the COR Policy and Procedure Manual 1.2 Contents and Layout 1.3 Provincial Standards 1.4 Acronyms 1.5 Glossary of Terms 2. Outline of Roles and Responsibilities 2.1 Outline of Roles and Responsibilities 3. Audits 3.1 Overview: COR Audit 3.2 Audit Registration 3.3 Certification Audit 3.4 Maintenance Audit 3.5 SECOR Audit Overview 3.6 SECOR Audit Conducted by a SECOR Assessor 3.7 SECOR Audit Conducted by an External Auditor 3.8 SECOR Assessor Code of Ethics 3.9 Overview: Maintenance Options 3.10 Action Plan 3.11 Safety Surveys 3.12 Overview: Additional Audit Types 3.13 COR Audit Equivalency (PASE) Program 3.14 Limited Scope Audit 3.15 Site Specific 3.16 Group Audit of Related Employers 3.17 Employers with Multiple WCB Accounts Table of Contents Approved: November 4, 2013 Page 1 of 4

2 3.18 Employers with Multiple Industry Classifications 3.19 Roll-up Audit 3.20 Team Audit 3.21 Injury Management / Return-to-Work Audit 3.23 Auditor Notes 3.24 Audit Sampling 3.26 Extending Audit Scope to Out-of-Province Temporary Work Sites 3.27 Out-of-Province COR 3.28 Use of Corporate Auditors 3.29 COR Audit Quality Assurance Review 3.30 SECOR Assessment Quality Assurance Review 3.31 SECOR External Audit Quality Assurance Review 4. Auditors 4.1 Overview of Auditor Qualifications 4.2 Auditor Certification 4.3 Auditor Recertification 4.4 Auditor Performance Management 4.5 Auditor Code of Ethics (See Appendix P: Auditor Code of Ethics) 4.6 On Site Audit Review 4.7 Verification Audit 4.8 Enform Employees as Auditors 5. Enform Audit Reviewers and Safety Audits and Certifications Staff 5.1 Standards for Audit Reviewers 5.2 Performance Management of Audit Reviewers 5.3 Code of Ethics for Audit Reviewers 5.4 Code of Ethics for Enform SA&C Staff 6. Certification 6.1 Overview of Certification (Process and Types) 6.2 Three Year COR/SECOR 6.3 Six Month COR 6.4 One Year Certificate of Recognition 6.5 MECOR Process 6.6 Injury Management / Return-to-Work Certification Table of Contents Approved: November 4, 2013 Page 2 of 4

3 6.10 Amendments to Certificates 6.11 Changing Certifying Partners 6.13 Fraudulent Certificates 6.14 Employer Review 7. Additional Certification Administration 7.1 Health and Safety Program Fee Structure 7.2 Extensions 7.3 Stakeholder Complaints Process 7.4 Retention of COR Records 7.6 Maintenance of COR/SECOR List 7.7 PIR Program Requirements (AB) 7.8 WorkSafeBC Rebate Requirements 7.9 Audit Protocol: Approval and Review 7.14 Certifying Partner Review 8. Training 8.1 Safety Program Development Course 9. Appendices Appendix A: WCB Industry Classifications Assigned to Enform Appendix B: COR Health and Safety Audit Protocol Appendix C: Injury Management / Return-to-Work Audit Protocol Appendix D: SECOR Audit Protocol Appendix F: Audit Worksite and Interview Sampling Tables Appendix H: Roll-Up Audit Forms Appendix I: Employer Report of Health and Safety Performance (for Out-of-Province Work Sites) Appendix J: Application for a Group Audit of Related Employers / PP103A Appendix K: Application for an Employer to use Corporate Auditors Appendix M: Sampling Plan Appendix N: COR Audit Quality Assurance (QA) Review Form Appendix O: SECOR Audit Quality Assurance (QA) Review Forms Appendix P: Enform Auditor Code of Ethics Appendix Q: Enform Certified Auditor s Agreement(s) Appendix R: On Site Audit Review (OSAR) Protocol Table of Contents Approved: November 4, 2013 Page 3 of 4

4 Appendix S: Stakeholder Complaint Form Appendix T: Enform Audit Reviewer Code of Ethics Appendix U: Enform Audit Reviewer Code of Ethics Declaration Appendix V: Enform Safety Audits & Certifications Staff Code of Ethics Appendix W: Enform Safety Audits & Certifications Staff Declaration Appendix X: Enform Extension Request Forms Appendix Y: Visual Guide to the Enform Auditor Performance Management Appendix : Safety Survey Quality Assurance Forms Appendix : Safety Survey Audit Tool Appendix : PASE Form (AB) Appendix : PASE Form (AB & BC) Appendix : COR Amendment Form Appendix 8.1.1: H & S Program Development Course Content Table of Contents Approved: November 4, 2013 Page 4 of 4

5 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 1.1 Introduction to the COR Policy and Procedure Manual Background Enform has developed the COR program policy and procedure manual to reflect its policies and procedures as it relates to all three provincial jurisdictions: Saskatchewan, Alberta, and British Columbia. As these are completed, they will be posted in.pdf form on Questions about specific policies should be directed to Policy Provincial Standards that Direct Enform Policy The standards of the Enform Health and Safety Program shall meet the minimum requirements set forth in the following documents: Partnerships: Standards for Certifying Partner Quality Assurance Systems (Alberta Employment and Immigration, June 17, 2008, and as amended and updated). The Certificate of Recognition Program: Standards and Guidelines (WorkSafeBC, January 2011, and as amended and updated). The Joint Industry Committee documents (WorkSafe Saskatchewan). Joint Industry Committee: Introduction to Framework of Standards for Health and Safety Programs (JIC , December 14, 2006). Joint Industry Committee: Framework of Standards for Health and Safety Program Audits (JIC , March 29, 2007). Joint Industry Committee: A Guide to the Framework of Standards for Health and Safety Audits (JIC , June 27, 2007). Joint Industry Committee: Framework of Standards for Certification and Quality Assurance (JIC , June 27, 2007) Enform currently does not offer the following provincial standards: Interview questionnaires Corrective Action Reports (CAR) Safety Surveys (perception surveys) Fixed Certification Date Element substitutions for COR maintenance 1.1 Introduction to the COR Policy and Procedure Manual Approved: March 11, 2013 Page 1 of 2

6 Use of Elements outside the audit standard Policy and Procedure manual approval and review process: The review process will occur when new or revised standards are communicated from the governing bodies The review process can also occur when clarification from staff is requested or operational changes occur The policy is drafted and reviewed, approved and signed by Enform management. Procedure General Information The policies in this manual indicate the rules Enform applies when interpreting and making decisions on issues The policy manual is provided to support the management of the COR program in ensuring decisions and interpretations are met in a consistent manner The table of contents outlines how this manual is organized All new or revised policies are developed to reflect all three provincial jurisdictions Policies are approved by the Manager, Safety Audits and Certifications For situations or issues not covered in this manual or situations that require special consideration, consultation with management for further direction is required The manual is intended to be a comprehensive document that will require updates and additions to reflect changes in standards and policies. This manual replaces any previous versions of policy documents or manuals. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 1.1 Introduction to the COR Policy and Procedure Manual Approved: March 11, 2013 Page 2 of 2

7 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 1.2 Content and Layout Background The content of this manual will provide users with information on Enform s Safety Audits and Certifications department s policies and procedures. Questions about specific policies and procedures should be directed to CORInfo@enform.ca. The day-to-day functional implementation of these policies and procedures is the responsibility of the Manager, Safety Audits and Certifications. Policy A concerted effort to see that these policies and procedures reflect the most current practice should be made. It is important that no policy or procedure be changed without incorporating the change in this manual. Enform reserves the right to change, modify or supersede any of these policies and procedures with or without notice at any time. Enform takes due care to ensure policies and procedures, when issued, are in compliance with governing body standards however, it is recognized that changes in standards may result in all or a portion of a policy and procedure becoming incorrect until necessary revisions are made. Procedure General Information The table of contents outlines how this manual is organized Readers should ensure they are using the current copy by comparing the date in the footer with the version they are viewing (i.e. online version). Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 1.2 Content and Layout March 16, 2013 Page 1 of 1

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10 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 1.4 Acronyms List of Acronyms AB AHS API ARS ASME BC BCRSP CAGC CAODC CAPP CAR CEO CEPA CHSC CHSMSA CMIS/WITS CoE COR CORRS CP Alberta Alberta Human Services Application Programming Interface Audit Registration System American Society of Mechanical Engineers British Columbia Board of Canadian Registered Safety Professionals Canadian Association of Geophysical Contractors Canadian Association of Oil-well Drilling Contractors Canadian Association of Petroleum Producers Corrective Action Report Chief Executive Officer Canadian Energy Pipeline Association Canadian Health and Safety Consultant Health and Safety Management System Auditor Compliance Management Information System/Wellsite Information Transfer Specification Code of Ethics Certificate of Recognition Certificate of Recognition Registration System Certifying Partner 1.4 Acronyms Approved: June 12, 2013 Page 1 of 3

11 CRSP CSA CSO CSP DIO DIR e.g. EIIPP H&S H2S HR IM/RTW IMS IQAS IRP ISO LAN LTCR MECOR MOU MSDS n/a OHS OJT ORR OSAR PA Canadian Registered Safety Professional Canadian Standards Association Construction Safety Officer Certified Safety Professional Documentation, Interview & Observation Disabling Injury Rate For example Employer Injury & Illness Prevention Program Health and Safety Hydrogen Sulfide Human Resources Injury Management/Return to Work Institute of Mathematical Statistics International Qualifications Assessment Service Industry Recommended Practice International Organization for Standardization Local Area Network Lost Time Claim Rate Medium Employer Certificate of Recognition Memorandum of Understanding Material Safety Data Sheets Not Applicable Occupational Health and Safety On the Job Training Outline of Roles and Responsibilities On-Site Audit Review Partnerships Administrator 1.4 Acronyms Approved: June 12, 2013 Page 2 of 3

12 PASE PC PEAT PIR PPE PRF PSAC PST QA SA&C SECOR SEPAC SK SMART TDG WCB WHMIS WTD Partnerships Audit Standard Equivalency Partnerships Consultant Potential Error Adjustment Template Partners in Injury Reduction Personal Protective Equipment Personal Reference Form Petroleum Services Association of Canada Petroleum Safety Training Quality Assurance Safety Audits and Certifications Small Employer Certificate of Recognition Small Explorers & Producers Association of Canada Saskatchewan Specific, Measurable, Attainable, Relevant & Timely goals Transportation of Dangerous Goods Workers Compensation Board Workplace Hazardous Materials Information System Weighted 1.4 Acronyms Approved: June 12, 2013 Page 3 of 3

13 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 1.5 Glossary of Terms Glossary Action Plan Administrative Audit Audit Audit Protocol Audit Report Auditor Auditor Notes Baseline Audit A process that allows employers who have held a valid COR for four or more consecutive years to use an alternative process for meeting maintenance audit requirements. Employers generate a series of specific health and safety initiatives, often based on previous audit deficiencies or recommendations, and are measured against their success in completing their initiatives within a calendar year. An audit conducted when an operation has no active sites to audit. These rely primarily on documentation review and interview sampling based on current staffing numbers. Administrative Audits are associated with the Six Month COR. An evaluation of an organization s health and safety management system against an approved standard. See also Administrative Audit, Baseline Audit, Certification Audit, Maintenance Audit, and Qualification Audit A technical specification that guides and directs the performance of an audit as well as the reporting structure and scoring. The written document produced by the auditor and provided to the client that provides the results of the auditor s evaluation of the client s health and safety management system against the audit protocol. An individual certified to conduct health and safety audits. Notes prepared by the auditor during the audit that explain the rationale used for determining the appropriate scoring. An evaluation using the standard audit protocol, and intended as a preliminary review of the employer s health and safety management system. 1.5 Glossary of Terms Approved: June 12, 2013 Page 1 of 5

14 Boilerplated Notes Certification Audit Certifying Partner (CP) Certified Auditor Compliance Corporate Auditor Corrective Action Report Certificate of Recognition (COR) Corrections Notes that are copies from notes prepared for previous employers or audit reports, which many or may not have been altered. A formal health and safety evaluation conducted in accordance with Enform s Certification/Recertification Audit standard in order to achieve a COR or SECOR. For large employers (11+ employees), a Certification Audit can only be conducted by a certified auditor external to the employer (or equivalent) and typically results in a three year certification. For small employers in the SECOR program, this audit may be carried out by either a Self-Assessor or External Auditor. An organization, typically an industry safety association or company working in the area of workplace safety, that has signed an agreement or memorandum of understanding with a provincial governing body to deliver a Certificate of Recognition program that meets the minimum standards defined by the agency. Enform is a recognized certifying partner for the oil and gas industry in Alberta and British Columbia. An auditor trained and certified by Enform. Adherence to standards, regulations and other Enform requirements. Auditors trained and certified by an employer to complete an employer-specific corporate audit document and process, and whose results will later be transferred to a Partnerships approved audit document to fulfill the requirements of the Partnerships Audit Standard Equivalency process. A process that allows employers who have held a valid COR for four or more consecutive years to use an alternative process for meeting maintenance audit requirements. The typical maintenance audit is replaced with an assessment by an employer of their Health and Safety Management system followed by a detailed plan for correction of deficiencies and improvements to be implemented. Technically it is the document issued by the certifying partner (Enform), sometimes in conjunction with a provincial governing body, that certifies an employer with 11 or more employees/contractors has a health and safety management system that meets established standards. The term COR is also used more informally to refer to smaller employer certification (technically SECOR) and the certification program as a whole. The required revisions of the submitted audit. 1.5 Glossary of Terms Approved: June 12, 2013 Page 2 of 5

15 Documentation Documentation Review Employee Employer External Auditor Group Audit Governing Body Health and Safety Management System Injury Management/ Return to Work Industry Classification Internal Auditor Interview Lead Auditor All of an organization s documents that relate to the safety management system, including policies, rules, standards, procedures, guidelines, practices, and records. Records include such items as meeting minutes, bulletins, inspection reports, preventive maintenance records, hazard reports, hazard analyses, emergency response drills, training records, and accident records. Part of a health and safety audit, designed to determine if an employer has the required processes, policies, and procedures in place, and if adequate records are being kept. Anyone who works for an organization (e.g., senior managers, managers, supervisors, and workers). Term used to represent the complete scope of an organization; the legal entity for whom employees work. An auditor trained by Enform to conduct audits for companies at which they are hired. An audit performed on individually incorporated companies, each with their own WCB accounts that function as a singular entity in terms of ownership and control but share a single health and safety management system. Any provincial agency or regulatory body that serves as a partner in the COR Program. is a systematic approach to managing safety, including the necessary organisational structures, accountabilities, policies and procedures A program to facilitate injured workers to stay at work or return to productive and safe duties as soon as physically possible after a workrelated incident. Employers are assigned an industry based on the business they conduct rather than by their employees' occupations. An auditor trained by Enform to perform audits for the company that they work for. Part of a health and safety audit. A method used to gather and verify information about an organization s health and safety system. Includes either formal discussion using standard questions, or a questionnaire. The head of the auditor team who has overall responsibility for organizing the audit team and carrying out the audit. 1.5 Glossary of Terms Approved: June 12, 2013 Page 3 of 5

16 Large Employer Limited Scope Audit Maintenance Audit Medium Employer Certificate of Recognition (MECOR) Observation Partnerships Audit Standard Equivalency (PASE) PASE Auditor PASE Report Policy OSAR (On-Site Audit Review) Qualification Audit Quality Assurance Roll Up Audit Sample For the purposes of the COR program, any employer with 11 or more employees. An audit that is conducted only on deficient areas of an employer s health and safety management system. A formal health and safety evaluation conducted by a certified auditor for an employer to maintain their COR status between formal recertifications. This process is designed for growing SECOR certified companies and new companies to the COR program with employees. Over the course of a three year cycle, employers transition from a SECOR to a COR based certification. Part of a health and safety audit designed to allow an auditor to observe and verify specific conditions at a work site. An audit protocol in which the results of an employer-specific corporate audit document and process are transferred to a Partnerships approved audit document to fulfill COR audit requirements. An auditor trained and certified by a Certifying Partner who has been contracted by a PASE-approved employer to transfer the corporate audit results to a Partnerships-approved audit document. The report document produced for the Certifying Partner in order to verify that the results of the employer s corporate audit process have met Partnerships standards. The documented principles by which an organization is guided in its management of affairs. An independent evaluation of the field work of a certified external auditor. A formal health and safety evaluation conducted by an auditor candidate pursuing auditor certification. A set of review activities intended to ensure that the completed audit satisfies Enform s audit standards requirements in a systematic, reliable fashion. Large employers with multiple business operations, units, worksites, or WCB accounts may find it beneficial to conduct audits on each of these individually. A roll-up audit allows these multiple individual audits to be submitted to Enform in the form of a single combined audit. A portion, piece, or segment that is representative of the whole. 1.5 Glossary of Terms Approved: June 12, 2013 Page 4 of 5

17 Representative Sampling Six-Month COR Small Employer Certificate of Recognition (SECOR) Small Employer Student Auditor Template Notes Verification Audit Worker Work Site Work Site Sampling A sample that accurately reflects the whole company and/or is of a sufficient quantity to reasonable and accurately assesses the whole. Granted when an existing COR is about to expire and, for a number of reasons, there are no work sites available to audit. The audit is confined to reviewing documentation and interviewing employees (an "Administrative Audit"). Technically it is the document issued by the certifying partner (Enform), sometimes in conjunction with a provincial governing body, that certifies an employer with 10 or less employees/contractors that has a health and safety management system that meets established standards. For the purposes of the COR program, any employer with 10 or fewer employees. An individual who has completed the classroom training required to conduct a student certification audit. Pre-crafted, ready-made notes that are used as a template, which may or may not have been altered, and form the basis of the Auditor s current report. An independent review of key areas of an employer s health and safety management system to validate that COR certification is justified. An employee supervised by a manager or supervisor/foreman. A location where a worker is, or is likely to be engaged in any occupation. A sample of sites where workers perform work that accurately reflects the work the company does. 1.5 Glossary of Terms Approved: June 12, 2013 Page 5 of 5

18 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 2.1 Outline of Roles and Responsibilities Background The Outline of Roles and Responsibilities sets out the framework for participation in Enform s Certificate of Recognition (COR), Medium Employer Certificate of Recognition (MECOR) process, Small Employer Certificate of Recognition (SECOR), and Injury Management/Return to Work (IM/RTW) certification programs. This document is to inform employers, Enform certified auditors, and certified auditor candidates about their role, to provide answers to frequently asked questions, and to set out a high-level summary of each stakeholder's responsibilities. Policy Employers must verify they have read and agree to the Outline of Roles and Responsibilities when they register with Enform as their certifying partner Auditors must verify they have read and agree to the Outline of Roles and Responsibilities each time they register an audit with Enform. Procedure Employers: Acknowledge having read and agree to the Outline of Roles and Responsibilities when they register with Enform as their certifying partner. Auditors: Acknowledge having read and agree to the Outline of Roles and Responsibilities when they register an audit with Enform. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 2.1 Outline of Roles and Responsibilities Approved: January 4, 2013 Page 1 of 1

19 Safety Audits and Certifications Outline of Roles and Responsibilities January 2013 Introduction The following Outline of Roles and Responsibilities sets out the framework for participation in Enform s Certificate of Recognition (COR), Small Employer Certificate of Recognition (SECOR), Medium Employer Certificate of Recognition (MECOR) process and Injury Management/Return to Work (IM/RTW) certification programs. The purpose of this document is to inform Employers, Enform Certified Auditors, and Certified Auditor Candidates about their role, to provide answers to frequently asked questions, and to set out a high-level summary of each stakeholder's responsibilities. More specific information can be found in Enform's policies, protocols and agreements. Employers, Enform Certified Auditors, and Certified Auditor Candidates who require additional information are encouraged to contact Enform directly. Contact information for Enform can be found at Legal Notice 1. This Outline of Roles and Responsibilities ("ORR") is not a binding agreement between Enform, Employers, Enform Certified Auditors, Certified Auditor Candidates ("Stakeholders"), or any other party 2. Enform does not make any representations or warranties in this ORR, and no party shall place any reliance, legal or otherwise, on the statements made in this ORR. 3. This ORR may be changed in form and/or substance by Enform without prior notice to any Stakeholder. 4. Provisions in this ORR are in some cases based on regulatory standards from government bodies, which are subject to change from time to time. 5. The roles and responsibilities set out in this ORR are superseded by any agreement that Enform may have with Stakeholders, which includes, but is not limited to, agreements between Enform and individual Enform Certified Auditors and agreements between Enform and provincial governing bodies. This ORR does not amend any of these agreements in any way. 6. Enform's obligations are found in the above-referenced agreements. This ORR does not create, modify or enhance existing or additional responsibilities for Enform that are not expressly set out in the above-referenced agreements. Page 1 of 6

20 Safety Audits and Certifications: Outline of Roles and Responsibilities January 2013 Outline of Roles and Responsibilities 1. Employer Eligibility Employers that are members of Enform are eligible for COR/SECOR/MECOR, IM/RTW and other program services through Enform for the upstream oil and gas industry, as identified by their WCB industry classification(s). Employers that are not members of Enform are also eligible for COR/SECOR/MECOR, IM/RTW and other program services through Enform, but additional fees will apply. COR certification is available to large Employers, defined as a company with 11 or more employees, and to smaller companies that choose to meet this standard. SECOR certification is available to small Employers, defined as a company with 10 or fewer employees. Employees include the owner(s) and any person(s) covered by the Employer s WCB account. The MECOR process is available to Employers with 10 to 19 employees who are transitioning from SECOR to COR certification. It is important to note, MECOR is not a separate type of COR certification. Employers participating in the MECOR process will hold a SECOR certificate until they successfully transfer to COR certification. IM/RTW certification is available to Employers that hold a valid COR. The continuation of the IM/RTW certification program is at the discretion of the provincial governing body. Employers must be in and remain in good financial standing with Enform and all applicable provincial governing bodies in order to apply for the various forms of certification. 2. Fees and Services Details of Enform s COR/SECOR/MECOR and IM/RTW fee structure can be found at Enform reserves the right to change its fee structure, without prior notice. No refunds or credits will be extended. 3. Confidentiality By registering for COR/SECOR/MECOR and/or IM/RTW services through Enform, Employers understand that information provided to Enform as part of the certification process will be shared by Enform with applicable governing bodies, as needed, in order to determine the eligibility of an organization for provincial certification and/or WCB incentives. As part of a service to certified Employers, Enform publishes a list of Employers who hold current Enform COR/SECOR certifications on the Enform website. If an Employer does not want their company's COR/SECOR certification status published on the Enform website, they must opt-out of this publication by sending an to Enform at corinfo@enform.ca confirming that they do not want to participate in this Enform service to Employers. As part of a service to certified Employers, Enform publishes a list of Certified Auditors qualified to conduct external COR/SECOR audits on the Enform website. Page 2 of 6

21 Safety Audits and Certifications: Outline of Roles and Responsibilities January 2013 If a Certified External Auditor does not want their name published on the Enform website, they must opt-out of this publication by sending an to Enform at corinfo@enform.ca confirming that they do not want to participate in this Enform service to Employers. Consent for Employers and External Auditors who do not opt-out of the publication of data on the Enform website will be deemed by their registration in the COR/SECOR certification process and/or the Auditor Certification process with Enform. 4. Enform s Role Enform: Provides COR/SECOR/MECOR, IM/RTW and other program services and, where applicable, acts in accordance with its memorandum of understanding (MOU) agreements with provincial governing bodies or other standard setting organizations. Upholds the applicable provincial COR/SECOR/MECOR, IM/RTW and other program standards. Provides training, certification, coaching and performance management for Enform Certified Auditors, and makes a list of Enform Certified Auditors in good standing available to Employers. Manages the audit process including: audit registration, consultation with Employers, Enform Certified Auditors and/or provincial governing bodies on audit issues, audit processing, performing audit quality assurance (QA) reviews, and performing on-site audit reviews when applicable. Applies for COR/SECOR, IM/RTW and other certificates from the provincial governing bodies or other standard setting organizations on behalf of Employers that have successfully passed all requirements of a certification audit (including having passed Enform's audit QA review). Maintains records on participating Employers and Enform Certified Auditors, as required by provincial governing bodies and other authorities. Enform does not: Set or negotiate the cost of conducting audits or the terms and conditions established between Employers and Enform Certified Auditors. Resolve any contract disputes between Employers and Enform Certified Auditors. 5. Employer s Role and Responsibilities The Employer will: Register with Enform for COR/SECOR/MECOR, IM/RTW and/or other program services it wishes to participate in. Familiarize itself and comply with any terms and conditions that are required by the provincial governing body for the Employer's participation in the COR/SECOR/MECOR, IM/RTW or other program services. Submit payment of the applicable fees prior to a new audit being registered. Page 3 of 6

22 Safety Audits and Certifications: Outline of Roles and Responsibilities January 2013 Update Enform on any company changes that may affect its certification as soon as those changes are known. Plan and schedule its audit in a timely fashion to avoid any lapse in certification. Be aware that student qualification audits may be used to maintain an Employer s COR only if the audit successfully passes QA review, but that student qualification audits cannot be used to certify or recertify an Employer s COR. Schedule its audit during active operational periods. Negotiate the terms and conditions, including financial considerations, for audit services directly with the Enform Certified Auditor. Participate in the audit process and provide the Enform Certified Auditor with any required information to complete the audit. Be responsible for resolving any contract disputes with the Enform Certified Auditor independent of involvement by Enform. Report in writing to Enform any concerns that it has, based on a reasonable belief, regarding an Enform Certified Auditor's performance, including unethical conduct. Retain a copy of its most recent audit (or maintenance option) report. Provide Enform with a copy of its most recent audit (or maintenance option) report upon request. Allow Enform, agents of Enform and/or provincial governing bodies to complete on-site audit reviews that provide quality assurance verification. The small Employer completing a SECOR Assessment will: Designate the owner or most senior operational employee familiar with the overall work operations to take the required SECOR training and complete the SECOR Assessment. Complete SECOR refresher training in accordance with Enform s standards. Register the SECOR audit with Enform prior to submitting the SECOR Assessment. Ensure that the person who performs the SECOR Assessment and the person who signs the SECOR Assessment abide by the SECOR Assessor Code of Ethics. Enform Certified Auditor s Role and Responsibilities Enform Certified Auditors: Perform all audit activities in accordance with Enform s current program standards, as set out in the documents referred to in the Enform Certified Auditor's Agreement. Comply with and are accountable to the requirements set out in the Enform Certified Auditor s Agreement. Conduct themselves at all times in a professional manner and in accordance with the Enform Auditor Code of Ethics. Maintain their auditor certification in accordance with Enform s standards. Only conduct those audits that they are approved by Enform to conduct. Page 4 of 6

23 Safety Audits and Certifications: Outline of Roles and Responsibilities January 2013 Register all audits with Enform prior to starting the audit. Report to Enform any changes (audit cancellation, change in audit type, etc.) to the original audit registration as soon as those changes are known. Perform the audit during the Employer s active operational periods. Use Enform COR, SECOR, IM/RTW and other applicable audit protocols and other audit materials that are current and made available to the Enform Certified Auditor at the time the audit is performed. Negotiate the terms and conditions, including financial considerations, for audit services directly with the Employer and complete the audit according to the agreed upon terms and conditions. Resolve any contract disputes with the Employer independent of involvement by Enform. Ensure all audit timelines specified by Enform are met, including: o o o o o 45 days for on-site information gathering activities, calculated from the first day of onsite activities. 45 days for audit report submission following the last day on-site. Enform strongly encourages Enform Certified Auditors to submit their audit reports as soon as possible after completion of on-site audit activities. 30 days to provide corrections for deficiencies identified in the audit QA review, calculated from the date that Enform informs the Enform Certified Auditor of the deficiencies. Having all deficiencies identified by Enform in the audit QA review corrected and approved by Enform within 90 days of the feedback date of the first draft of the report. Completing on-site audit activities by December 31 st for a given calendar year, if the audit is being used to achieve or maintain COR/SECOR, IM/RTW or other certification. Provide a final printed copy of the audit report to the Employer once the audit has passed the audit QA review carried out by Enform. Acknowledge that on-site audit reviews may be performed to provide quality assurance verification. Certified Auditor Candidate s Role and Responsibilities The Certified Auditor Candidate must successfully complete all steps in Enform s Certified Health and Safety Auditor Program, including application, taking and passing the Certified Health & Safety Auditor Program, successfully completing a student qualification audit, and signing the Enform Certified Auditor's Agreement before he or she is considered an Enform Certified Auditor. The Certified Auditor Candidate's role is to: Perform all audit activities in accordance with Enform s current program standards. Register his or her student qualification audit with Enform prior to starting the audit. Page 5 of 6

24 Safety Audits and Certifications: Outline of Roles and Responsibilities January 2013 Report to Enform any changes (audit cancellation, change in audit type, etc.) to the original audit registration as soon as those changes are known. Use the Enform COR audit protocol and other audit materials that are current at the time the audit is performed. Perform the audit during the Employer s active operation. Inform Employers that student qualification audits may be used to maintain an Employer s COR only if the audit successfully passes QA review, but that student qualification audits cannot be used to certify or recertify an Employer s COR. Ensure all audit timelines specified by Enform are met, including: o o o o o o o Completing the Enform Certified Health and Safety Auditor Course within twelve months of the date when Enform approves the individual's candidacy to become an Enform Certified Auditor Submitting the student qualification audit within six months from the last day of the Enform Certified Health and Safety Auditor Training Program. 45 days for on-site information gathering activities, calculated from the first day of onsite activities. 45 days for audit report submission following the last day on-site. Enform strongly encourages Certified Auditor Candidates to submit their audit reports as soon as possible after completion of on-site audit activities. 30 days to provide corrections for deficiencies identified in the audit QA review, calculated from the date that Enform informs the Certified Auditor Candidate of the deficiencies. Having all deficiencies identified by Enform in the audit QA review corrected and approved by Enform within 90 days of the feedback date of the first draft of the report. Completing on-site audit activities by December 31 st for a given year, if the audit is being used to maintain COR certification. Provide a final printed copy of the audit report to the Employer once the audit has passed the audit QA review carried out by Enform. Acknowledge that on-site audit reviews may be performed to provide quality assurance verification. Page 6 of 6

25 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 3.1 Overview: COR Audit This section of the manual outlines policies and procedures for the process of an employer engaging in achieving COR certification with Enform. Eligibility requirements to participate are outlined as well as registration requirements for both the auditor and employer. All employers are required to follow maintenance requirements for COR Certification as outlined in the policy in this section. Questions about specific policies or procedures should be directed to or option Overview: COR Audit April 12, 2013 Page 1 of 1

26 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 3.2 Audit Registration Background As outlined in the Safety Audits and Certifications Outline of Roles and Responsibilities, the auditor has a responsibility to register all audits performed by an auditor with Enform prior to starting the audit. The Audit Registration System (ARS) provides support, guidance and enhanced customer service to both the employer and auditor while ensuring the audit process proceeds successfully to completion and meets all required timelines. This policy and procedure does not apply to SECOR assessors. Policy The auditor is responsible for the following in regards to audit registrations: Register all audits with Enform prior to starting the audit Report to Enform any changes (audit cancellation, change in audit type, etc.) to the original audit registration as soon as those changes are known. Procedure The employer will: Hire a current auditor to conduct the audit o o o For certification/recertification audits the current Enform Petroleum Industry External Auditor list posted on the Enform website is to be used. For maintenance audits the employer can choose to train a full time employee to become an internal auditor to conduct their audits. Alternatively, they may hire an external auditor on the Enform Petroleum Industry External Auditor list to conduct maintenance audits. All auditors hired must be in good standing and have current certification. Certification can be verified by contacting Enform. Familiarize and comply with any timelines for the audit process as outlined in the Safety Audits and Certifications Outline of Roles and Responsibilities. Once the notification of registration is received, non-members are to submit any applicable fees to Enform in a timely manner to avoid delays in audit commencement. 3.2 Audit Registration Approved: June 10, 2013 Page 1 of 3

27 Provide any information required by Enform to assist with the registration process. Once the audit starts, follow up periodically with the auditor to ensure all details of the contractual agreement for the audit process are being met. Receive and track applicable notifications from Enform on audit submission, audit review and audit approval. If any notifications are missed, follow up immediately with the auditor and/or Enform to determine the status. The auditor will: Use the online registration system, registers the audit prior to the start of the audit. o Considerations should be made when selecting a start date to allow for enough time for the following: For non-member employers to make necessary payment arrangements with Enform. For Enform to perform necessary quality assurance checks on the submitted audit registration. Provide any information required by Enform to assist with the audit registration process. Student auditors registering qualification audits must take into consideration the 6 month timeframe deadline for submitting student audits. o o For student only qualification audits, the timeframe is 6 months from the last day of the Certified Health and Safety Auditor course. For student qualification and COR maintenance audits the timeframe is 6 months from the last day of the Certified Health and Safety Auditor course or December 31st, whichever occurs first. During the course of the audit if sampling requirements change and minimum sampling requirements are being jeopardized, the auditor is to consult with the employer to make any necessary changes such as: o o o Delaying the audit so minimum sampling requirements can be met (on site activities must be complete prior to December 31st of the calendar year). Discuss alternate interview persons or sites to reach minimum sampling. If any of the above two points are not obtainable for meeting minimum sampling, the employer and auditor must approach Enform for discussion on solutions or next steps. Notify Enform of any changes to the original approved audit registration details by completing the Audit Change Request through the online registration system. 3.2 Audit Registration Approved: June 10, 2013 Page 2 of 3

28 Enform will: Perform a QA review on the submitted audit registration to check for the following: o o o o o o Auditor credentials. Company information. WCB account validation. Audit type. Member/non member status. Assess requirement for additional applications for team audit, audit plans or one audit covering multiple companies (PP013A form). Review and process the audit registration in a timely manner, including invoicing and sending payment required notices to the employer. Communicate and request missing or additional information from the employer and/or auditor. Enter and request necessary registration information with applicable government body online systems (CORRS and icor). Arrange to communicate audit registration approval or non-approval notice to the employer and auditor. Provides the license key to the auditor. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 3.2 Audit Registration Approved: June 10, 2013 Page 3 of 3

29 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.3 Certification Audit Background The certification audit is the cornerstone of the COR program. It provides external verification that an employer s health and safety management system meets COR program standards. To qualify for an Enform COR, an employer must have a certification audit carried out by an Enform certified external auditor, with the resulting audit report submitted to Enform within 45 days of the audit completion date. To achieve a COR, the audit must achieve a minimum score of 80% overall, and 50% on each audit element, as well as pass Enform s audit quality assurance (QA) review. A COR resulting from a standard certification audit is valid for three years, provided annual maintenance requirements are met. Typically, employers will have a certification audit carried out toward the end of the three year period. However, employers may renew their COR for another three year period at any time by conducting a successful certification audit. Policy To qualify for a certification audit, an employer must: Have had their health and safety management system in place for at least one year. Employers that cannot meet this requirement may consider the option of a One Year COR Have active work sites available to audit. Employers that cannot meet this requirement may consider the option of a Six Month COR The auditor must: Be an Enform certified external auditor prior to initiating the audit. Large, complex organizations have the option of using corporate auditors for certification audits based on Enform s standards regarding corporate auditors Be in compliance with the Enform Auditor Code of Ethics. It is especially important that there is no conflict of interest in carrying out an audit for a specific employer Register the certification audit with Enform prior to the audit start date. 3.3 Certification Audit Approved: March 15, 2012 Page 1 of 3

30 Complete all on site data gathering activities within 45 days Submit a completed audit report to Enform within 45 days from the last day of on site data gathering activities Address any deficiencies and required corrections arising from the audit QA review within 30 days Provide the employer with the final version of the audit report after it has successfully completed Enform s audit QA review The certification audit must: Be conducted using the current Enform audit protocol Maintain the audit scope set out in the audit registration process Follow standards for minimum and representative sampling for interviews and number of worksites reviewed Be subjected to an audit QA review by Enform whether or not it achieves the minimum score required for COR certification Be retained by Enform until the employer s subsequent maintenance audit or certification audit is received For the employer to achieve COR certification, the audit must: Achieve a minimum score of 80% overall with no less than 50% on each audit element. Audits that score between 70-80% may still be eligible for a limited scope audit (see 3.13 Limited Scope Audit) Successfully pass an audit QA review by Enform Enform shall be responsible to: Procedure The employer: Verify that auditors are fully certified at the time of audit registration Provide a timely audit QA review on all certification audits Inform the relevant governing bodies of successful COR certification audits Provide notification to employers when the audit QA review is complete. Contracts the services of an Enform certified external auditor. Provides the necessary information and cooperation the auditor requires to complete their audit to the Enform COR audit protocol. 3.3 Certification Audit Approved: March 15, 2012 Page 2 of 3

31 The auditor: Ensures they are in compliance with the Enform Auditor Code of Ethics. Negotiates contractual terms and fees with the employer. Registers the audit with Enform providing accurate WCB account information for the scope of the audit and estimated interview and worksite sampling o Auditors may also confirm compliance with interview and worksite sampling criteria in advance by submitting an audit plan to Enform. Uses the current Enform audit protocol to conduct the audit. Provide a change of audit registration for any changes to the audit start date or scope or cancellation of the audit. Ensures that the on site data gathering activities do not exceed 45 days. Submits the completed audit report to Enform electronically within 45 days of the last day on site. Addresses any deficiencies identified in the audit QA review within 30 days of notification. Provides the employer with the final audit report. o The final audit report must be provided after the audit QA review is complete as it should include any corrections or additions arising from the audit QA review. Enform: Receives and approves the audit registration request. o Enform provides feedback on any audit plans it receives as part of the audit registration process. Performs an audit QA review in accordance with the Enform audit QA review policy. Provides feedback to the auditor once audit QA review is complete. Sends a notice to both the employer and the auditor. o The employer receives a notice that the audit QA review is complete and that they can expect to receive the final version of the audit to be delivered by the auditor. o The auditor receives a reminder to provide the employer with the final version of the audit. Maintains a copy of the final audit report until the next completed audit. Registers the successful certification audit with the appropriate governing bodies. o For employers outside Alberta and British Columbia, Enform generates and sends the COR certificate. Approval Paula M.A. Campkin, MBA, CRSP Manager, Safety Audits and Certifications 3.3 Certification Audit Approved: March 15, 2012 Page 3 of 3

32 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.4 Maintenance Audit Background A regular COR is valid for three years from date of issue (last day of external audit). To maintain certification and remain eligible for any associated provincial WCB benefits, employers must perform annual maintenance audits or approved maintenance options in the two intervening years. Annual maintenance audits or options must be completed by December 31 of the calendar year. Unlike the COR certification audit that requires an external auditor perform the audit, COR maintenance audits can be conducted by an internal auditor or by a student auditor (as part of their auditor certification process). With certification audits, the emphasis is on third party verification of the employer s health and safety management system. In the maintenance audit, the emphasis is on internal efforts to ensure the health and safety management system is properly maintained and continuously improved. There are no minimum scoring requirements to pass a maintenance audit. However, a maintenance audit score that falls below that standard (80% overall and 50% in each element) should serve as an important indicator that an employer s health and safety management system may be in danger of failing the next certification audit. This policy outlines the requirements for a basic maintenance audit. Enform also offers a number of audit options, for employers who meet the pre-set criteria that can be used in place of the maintenance audit (see 3.9 Overview: Maintenance Options). Policy Employers are required to complete a COR maintenance audit in the two subsequent calendar years after successfully completing a COR certification audit Enform shall inform employers of the requirement to perform maintenance audits following a successful COR certification audit and on an annual basis An employer may also choose to renew their COR certification early by conducting a certification audit in a maintenance year Maintenance audits must be conducted on active work sites Audits should be timed so they can be conducted when during high to medium levels of workplace activity and when these activities are representative of the employer s operations. 3.4 Maintenance Audit Approved: March 28, 2012 Page 1 of 4

33 Employers operating in seasonal industries or with temporary worksites and who experience fluctuating activity levels due to changes in the general economic conditions may audit based on their best estimate of high to medium activity, provided that they have at least one active worksite Employers acquiring or developing new operations (additional industries, new facilities, large influx of new staff, etc.) may be required to perform a certification audit instead of a maintenance audit The maintenance audit must cover the same scope of operations as the original certification audit This includes certification audits that covered multiple industry classifications, multiple WCB accounts, or provincial jurisdictions, the maintenance audit must also cover these same industry classifications, WCB accounts, and/or provinces This does not include a certification audit carried out as a group audit of related employers where maintenance audits can be carried out on individual employers (see 3.16 Group Audit of Related Employers) Maintenance audits must be completed by: A certified external auditor, or A certified internal auditor for the employer seeking the Maintenance Audit, or An eligible student auditor that has successfully completed the Enform auditor training programming and is seeking to complete an audit for auditor certification purposes The auditor must: Register the maintenance audit with Enform prior to the audit start date Complete all on site data gathering activities within 45 days Submit a completed audit report to Enform within 45 days from the last day of onsite data gathering activities Address any deficiencies and required corrections arising from the audit QA review within 30 days of notification and within 90 days of the first notification of QA deficiencies Provide the employer with the final version of the audit report The maintenance audit must: Be conducted using the current Enform audit protocol As much as reasonably possible, maintain the audit scope set out in the audit registration process Follow standards for minimum and representative sampling for interviews and number of worksites included in the audit Successfully pass the Enform audit QA review Have onsite audit activity completed before the end of the calendar year (December 31). 3.4 Maintenance Audit Approved: March 28, 2012 Page 2 of 4

34 Where required by governing bodies, be scheduled so that maintenance audits are at least 6 months apart The employer s maintenance audit is not required to achieve the COR scoring standard (at least 80% overall, with no less than 50% in each element) Enform will retain the employer s maintenance audit on file until the Employer s subsequent maintenance or certification audit is received and approved If an Employer does not meet their maintenance requirement, Enform will cancel their COR Enform will contact the employer to advise them that their COR is no longer valid If applicable, Enform will request cancellation of the employer s COR with the applicable governing body. Procedure The employer: Seeks Enform auditor training for a company employee to serve as an internal auditor, retains an Enform certified internal auditor as an employee, or contracts the services of an Enform certified external auditor. Provides the necessary information and cooperation the auditor requires to complete their audit. The auditor: Registers the audit with Enform. o Auditors may include an audit plan proposing an interview and work site sampling to confirm compliance to Enform standards as part of the audit registration process. Uses the current Enform COR audit protocol to conduct the audit. Ensures that the onsite data gathering activities do not exceed 45 days. Submits the completed audit report to Enform within 45 days of the last day on site. Addresses any deficiencies identified in the audit QA review within 30 days of notification. Provides the employer with the final audit report. o The final audit report is provided after the audit QA review is complete so that it includes any corrections or additions arising from the audit QA review. 3.4 Maintenance Audit Approved: March 28, 2012 Page 3 of 4

35 Enform: Receives and approves the audit registration request. o Enform provides feedback on any audit plans it receives as part of the audit registration process. Performs an audit QA review in accordance with the Enform audit QA review policy once the audit is submitted. Provides notice to the auditor and the employer once Audit QA Review is complete. o This notice informs both parties of the requirement that the employer must receive the final version of the audit report from the auditor. Maintains a copy of the final audit report until the next completed audit is submitted and approved. Registers the completion of a maintenance audit with the appropriate governing bodies, if applicable. In the event that an employer fails to conduct or provide a successful Maintenance Audit within the calendar year, Enform: o Informs the Employer that their COR is no longer valid. o Removes the Employer from the official list of Enform COR holders. o Informs the relevant governing bodies that the Employer s COR has been cancelled. Approval Paula M.A. Campkin, MBA, CRSP Manager, Safety Audits and Certifications 3.4 Maintenance Audit Approved: March 28, 2012 Page 4 of 4

36 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 3.5 Overview: SECOR Assessment This section of the manual outlines policies and procedures for the process of an employer engaging in achieving SECOR certification with Enform. Eligibility requirements to participate are outlined as well as registration requirements for the assessor, auditor and employer. Questions about specific policies or procedures should be directed to or option SECOR Audit Overview Approved: April 12, 2013 Page 1 of 1

37 HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.6 SECOR Assessment Conducted by a SECOR Assessor Background Small employers (10 or fewer employees) may pursue a Small Employer Certificate of Recognition (SECOR) by using Enform s audit standard specifically designed to meet the application and training needs of small employers. The SECOR program provides these owner-operators and employers a manageable and cost-effective means of participating in the COR program. The SECOR has been designed to enable the owner, senior operational person, or an employee familiar with the overall work operation to serve as a SECOR assessor and complete the SECOR report. Employers in the SECOR program also have the option of using an Enform external auditor to complete their SECOR report. For this latter option see policy and procedure 3.7 SECOR Audit Conducted by an External Auditor. Policy Small employers who are eligible for the Enform SECOR certification must: Have no more than 10 employees at any given time. This includes owners and any person (including contractors) covered by the employer s WCB account. If an employer s workforce exceeds 10 employees during a SECOR maintenance year, Enform will still accept a SECOR-based assessment. However, the following year the employer must move either into: o A MECOR program that begins with a SECOR certification assessment performed by an Enform certified external auditor; or o A standard COR program starting with a COR certification audit Have the owner, most senior operational person, or an employee familiar with the overall work operation successfully complete the Enform Safety Program Development course. This individual is then eligible to function as the SECOR assessor. The SECOR assessor is responsible to attend every three years an Enform-approved training course or approved elective course (based on the anniversary date of the most recent required training course). o SECOR assessors that carry current credentials as Enform certified auditors are exempt from this requirement. 3.6 SECOR Assessment Conducted by a SECOR Assessor Revised: March 13, 2013 Page 1 of 4

38 o Enform offers additional courses that are pre-approved as courses to be taken in lieu of the one day SECOR Refresher course. All requirements related to the SECOR Refresher course apply equally to these electives. A list of these additional courses will be kept current on the Enform website. If the SECOR assessor leaves the employer, the employer must have a replacement trained within 90 days (or earlier if there is an impending SECOR assessment deadline). The requirement that the SECOR assessor be fully up to date with the refresher course before the SECOR assessor is submitted to Enform will only be waived under the following circumstances: o Enform has cancelled a refresher or approved elective course the SECOR assessor was planning on taking to meet requirements. o There are no additional refresher or approved elective courses available until after the employer s SECOR expires. o The SECOR assessor is registered in the next available refresher or pre-approved course. An employer may elect to have another employee fulfill all the Enform Safety Program Development course training requirements and have this individual complete the SECOR assessment. o In this scenario, the owner, most senior operational person, or employee familiar with the overall work operations must still fulfill all of the above training requirements and remain responsible to sign off on the SECOR report Have had their health and safety management system in place for a full year to meet documentation requirements. Employers that have not implemented a health and safety management system for a full year may still be eligible for a one year SECOR (See 6.4 One Year Certificate of Recognition) The SECOR assessment must: Be completed by the same individual that has completed the Enform Safety Program Development course and remains current by completing the one day SECOR Refresher or approved elective course every three years. In the event that an employer elects to train an additional employee to undertake the SECOR assessment, the final report must still be signed by the owner, most senior operational person, or employee familiar with the overall work operations that has completed the Enform Safety Program Development course and remains current. 3.6 SECOR Assessment Conducted by a SECOR Assessor Revised March 13, 2013 Page 2 of 4

39 Be performed using Enform s SECOR submission package and include: Supporting documentation as required by the SECOR submission package. An action plan addressing any deficiencies noted in the SECOR report. A signed, dated agreement that expresses the SECOR assessor s compliance with the Enform SECOR Assessor Code of Ethics and all other applicable Enform standards. An additional signature of approval from the owner, most senior operational person, or employee familiar with the overall work operations where another employee has served as the SECOR assessor Be completed within the following timelines: No more than 45 days from the start of the desktop assessment activities to the end of gathering documents and data for the SECOR report itself. o The documents that will be included in the SECOR report are typically written and compiled over the course of a year this timeline applies only to collecting documents for the purposes of including in the audit. No more than 45 days from the end of information gathering to submit the completed SECOR report to Enform Pass Enform s audit QA review (see 3.30 SECOR Audit Quality Assurance Review) A SECOR assessment for certification must produce a minimum overall score of 80% with 50% or greater in each element While there are no minimum scoring requirements for a maintenance SECOR assessment, the report itself (including supporting documentation) must be of sufficient quality to pass the Enform audit QA review Enform shall inform employers that have expanded beyond 10 employees during their maintenance years that they will be required to switch to the MECOR process or the COR program the following year Enform shall maintain a copy of SECOR QA review and action plan for a minimum of a year. Procedure The small employer: Ensures the owner, most senior operational person, or employee familiar with the overall operations has successfully completed the Enform Safety Program Development Course and is up to date with the required SECOR Refresher course or approved elective courses. If the report write up will be conducted by an employee other than this person, ensure the report writer has also met all of the SECOR training requirements. 3.6 SECOR Assessment Conducted by a SECOR Assessor Revised March 13, 2013 Page 3 of 4

40 The SECOR assessor: Conducts the SECOR assessment using the Enform SECOR assessment protocol. Ensures the information gathering activities do not exceed 45 days and that the final SECOR report is submitted to Enform within 45 days of completing these activities. Signs and adheres to the SECOR Assessor Code of Ethics. May be required to provide corrections, clarification, or additional information to address deficiencies noted in the Enform QA review. o These must be provided within 30 days of being notified by Enform that they are required. Enform: Verifies that the SECOR assessor s training requirements are fulfilled upon submission of the SECOR report. Performs an audit QA review applicable to the SECOR protocol. o This may require the SECOR assessor to correct, clarify, or provide additional information in order for the report to pass QA review. Informs the small employer of the success or failure of their SECOR assessment upon completion of the QA review process. Provides feedback to the SECOR assessor and employer as appropriate. If a successful certification SECOR assessment, Enform either provides a SECOR certificate directly or informs the appropriate governing body in order to initiate the SECOR certification process. If a successful maintenance SECOR assessment, Enform records successful maintenance of the SECOR and, where required, notifies the appropriate governing body of successful maintenance of the SECOR. Cancels any SECOR certificates that are not successfully maintained. Maintains a copy of the completed QA review and action plan until the next SECOR assessment is complete. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.6 SECOR Assessment Conducted by a SECOR Assessor Revised March 13, 2013 Page 4 of 4

41 HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.7 SECOR Audits Conducted by an External Auditor Background Small employers in the SECOR program may opt to use an Enform certified external auditor to perform their SECOR certification or maintenance audits. In the case of the MECOR Process, a SECOR Audit conducted by an external auditor is required. While many of the policies and procedures of the SECOR audit conducted by a SECOR assessor are applicable the SECOR audit carried out by an external auditor, there are some important differences that are captured in the policy below. The policies and procedures regarding SECOR employers and SECOR audits conducted by a SECOR assessor are applicable unless otherwise stated in the following policy and procedure. Policy Employers using an external auditor to conduct their SECOR audit must follow the same requirements as the SECOR audit conducted by a SECOR assessor with respect to the owner, most senior operational person, or employee familiar with the overall operation successfully completing the Enform Safety Program Development course Refresher course requirements outlined in 3.6 SECOR Audit Conducted by a SECOR Assessor apply as well The external auditor performing the SECOR audit must be an Enform certified external auditor The external auditor must complete all required auditor training on the SECOR audit in advance of starting a SECOR audit The SECOR audit conducted by an external auditor must: Be performed using Enform s SECOR audit protocol and include: A review of supporting documentation as directed by the Enform SECOR audit protocol. o Unlike the SECOR audit conducted by a SECOR assessor, the documentation itself does not need to be submitted with the SECOR audit. Evidence of correct application of the validation methods directed by the audit document. Notes justifying scoring as well as strengths and recommendations for each audit element. An action plan addressing any deficiencies noted in the audit report. 3.7 SECOR Audits Conducted by an External Auditor Approved: March 27, 2012 Page 1 of 3

42 Adhere to the standard audit timeline requirements of other COR audits. This includes a 45 day limit for on site information gathering activities and a 45 day limit to submit the audit report after the last day of on site information gathering activities Be signed by the external auditor Enform shall perform an audit QA review on all SECOR audits conducted by external auditors in accordance with 3.30 SECOR Audit Quality Assurance Review. Procedure Enform shall maintain the audit QA review and action plan documents until the employer s subsequent audit is completed. The small employer: Ensures the owner, most senior operational person, or employee familiar with the overall operations has successfully completed the Enform Safety Program Development course and is up to date with the required SECOR Refresher course. Contracts the services of an Enform certified external auditor. The auditor: Registers the SECOR audit prior to beginning the audit. Completes a training session on the SECOR audit as required if they have not already done so. Conducts the SECOR audit using the Enform SECOR audit protocol. Works within the same time requirements as a standard COR audit for on site information gathering, report writing, and response to QA issues. Provides the employer with the final form of the SECOR audit report that has passed audit QA review process. Enform: Collects and verifies the following during SECOR Audit registration: o Employer s Safety Program Development Course / Refresher Course requirements are fulfilled. o External auditor s qualifications. Performs an audit QA review applicable to the SECOR audit protocol. o This may include informing the auditor of any deficiencies in the audit report that must be addressed to pass QA review. o Confirms any identified deficiencies are adequately addressed by the Auditor when the SECOR audit is resubmitted. Informs the auditor of the status of the audit QA review. Informs the small employer of the status of the audit QA review process. o Enform will inform both auditor and employer of the requirement to provide the employer with the final version of the audit report. 3.7 SECOR Audits Conducted by an External Auditor Approved: March 27, 2012 Page 2 of 3

43 Follows standard practices with respect to: o Providing or applying for SECOR certificates for employers that succeed with their SECOR audits for certification purposes. o Notifying employers and, as required, updating governing bodies, to confirm successful maintenance of their SECOR. o Maintaining a copy of the completed QA review and action plan until the next audit is complete. o Cancelling SECOR certificates. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.7 SECOR Audits Conducted by an External Auditor Approved: March 27, 2012 Page 3 of 3

44 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.8 Enform SECOR Assessor Code of Ethics Background In the SECOR program, employers may provide a SECOR audit by the owner or senior operational person within the company. As such, it is important that the assessor that carries out the SECOR audit maintains the highest degree of accuracy, honesty, and professionalism. The Enform SECOR Assessor Code of Ethics provides employers conducting a SECOR audit a clear guide to Enform s expectations in this regard. Violations of the SECOR Assessor Code of Ethics will be investigated and addressed by Enform as appropriate. Policy The Enform SECOR Assessor Code of Ethics includes the following expectations: Professionalism and Integrity SECOR assessors are expected to hold themselves to the highest standards of honesty and professionalism in conducting SECOR audits. The behaviour of a SECOR assessor should not call into question their good faith and integrity. SECOR assessors are prohibited from using the intellectual property or information obtained from either Enform or the employer for personal gain SECOR Audit Conduct In conducting SECOR audits, Enform SECOR assessors are expected: o To maintain confidentiality Assessors should ensure that information provided in confidence in the SECOR audit interview process is respected as such and to protect the anonymity of interviewee responses in SECOR audit reporting. o To be diligent. Assessors must act in good faith, with due care and competence, without misrepresenting material facts or allowing their independent judgment to be compromised. o To be objective Assessors must be objective in the assessment of their workplace health and safety management systems and base their evaluations on objective and measurable data, and not subjective opinions or assumptions. 3.8 Enform SECOR Assessor Code of Ethics March 22, 2017 Page 1 of 3

45 o o o o o o To be accurate. Assessors must strive for accuracy and consistency in compiling documentation, and in the delivery of interview results in their SECOR audit report documents. To be complete Assessors must ensure their evaluations are complete, and avoid any omissions relevant to the scope of the audit. To be relevant Assessors must ensure their action items and suggestions for improvement in the SECOR audit report are relevant and are intended to improve the health and safety management system. To be clear. Assessors must ensure their notes and documentation are clear, concise, reflect their findings, and written in plain language. To be timely. Assessors must comply with the required timelines for SECOR audit completion, submission, and correction. To report. Assessors must report to Enform a situation where an auditor or another assessor may have violated the Code of Ethics or engaged in unethical audit practices Compliance Enform SECOR assessors must follow all of the SECOR audit and SECOR audit quality assurance standards as established by Enform and its provincial partners, and any applicable legislated requirements while conducting and completing the SECOR audit Assessors are required to sign a dated statement of agreement that expresses their compliance with the Enform SECOR Assessor Code of Ethics and all other applicable Enform standards Signed and dated statements of agreement must be included with the submission of each SECOR audit Enform retains the right to investigate employers and their assessors that it has reason to believe have not been compliant with the SECOR Assessor Code of Ethics If an investigation of a breach of the SECOR Assessor Code of Ethics substantiates a significant ethical issue by the employer and/or assessor, Enform may impose disciplinary consequences, including: Suspending the assessor Rejecting the SECOR audit and requiring a second SECOR audit Rejecting the SECOR audit and cancelling SECOR certification Refusing to offer SECOR certification services to the employer indefinitely. 3.8 Enform SECOR Assessor Code of Ethics March 22, 2017 Page 2 of 3

46 Procedure The assessor for a SECOR audit: Signs and submits the statement of agreement to comply with the SECOR Assessor Code of Ethics with each SECOR audit. Conducts themselves in a manner that is consistent and compliant with the SECOR Assessor Code of Ethics when carrying out a SECOR audit. Enform: Checks for and maintains a record of the signed assessor statement of agreement that is submitted with each SECOR audit. Investigates assessor conduct if there is reasonable ground to suspect a breach of the SECOR Assessor Code of Ethics. As a result of such an investigation, where there is a significant ethical breach, Enform may: o Suspend the assessor or reject the SECOR audit if an investigation substantiates a significant ethical breach. o Impose additional penalties such as removing and/or refusing SECOR certification to the employer. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.8 Enform SECOR Assessor Code of Ethics March 22, 2017 Page 3 of 3

47 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 3.9 Overview: Maintenance Options This section of the manual outlines policies and procedures for the process of an employer engaging in maintenance options for their annual COR maintenance requirements with Enform. Eligibility requirements to participate are outlined as well as application requirements for both the auditor and employer. Questions about specific policies or procedures should be directed to or option Overview: Maintenance Options Approved: April 13, 2013

48 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.10 Action Plan Policy This procedure provides an overview of the requirements and responsibilities for an employer wanting to perform an Action Plan as a maintenance option. Action plan items must be measureable, and designed to introduce meaningful improvements to the employer s OHS management system Scope Action Plans may be performed in lieu of a maintenance audit. This option is available to employers holding a Certificate of Recognition (COR) and meet the following criteria: Must be in a maintenance year and completed a full three year COR audit cycle. In situations where the employers completes a certification audit each year, eligibility for an Action Plan is after 3 certification audits have been completed. The last certification audit achieved 85% or higher as an overall score, or if applicable achieved 80% or higher in last year s action plan. Action Plans in lieu of COR Maintenance are currently accepted in Alberta, Saskatchewan and British Columbia (BC). British Columbia COR Audit holders also require approval from WorkSafeBC. SECOR and MECOR are not eligible for Action Plans. Large and complex employers with multi-sites, multiple accounts and/or related employers originally included together in the same certification audit may submit separate Action Plans for each of their sites, accounts, or related employers. Provided: The employer's individual Action Plans must cover the same scope of operations as would be included if the employer was submitting one regular Action Plan. All the Action Plans must be reviewed and approved as a whole. For example, if one of the submitted Action Plans did not meet the scope of operations, the other Action Plans would not receive approval until revised. Supporting Documents The following listed documents provide further information for Action Plans: Appendix L3 This work instruction provides all the information an employer requires to complete and submit an Action Plan Appendix L2 This form is used by the employer to apply do an action plan. Appendix L1 This form is used to develop and record the company s action plan 3.10 Action Plan Approved December 15, 2015 Page 1 of 3

49 Appendix L4 - This form used by Enform reviewers to document the quality assurance results. Appendix L5 - This form used by Enform reviewers to document comments for the employer under the quality assurance results Appendix L6 This work instruction is used to describe Enform s internal administrative process for Action Plans. Roles & Responsibilities The following are roles and responsibilities of employers, auditors, and Enform: Employers Ensure action plans include recommendations from previous COR audits, where applicable Action Plans may also include corporate health and safety initiatives that may be outside the scope of the COR audit. Complete the Action Plan Application Form and submit to Enform for approval no later than January 31 of the current year. Note - for BC COR holder s additional approval is required by WorkSafeBC. Approved employers must submit their proposed Action Plan objectives by March 31 of the same year for approval. Submit any amendments to Action Plan by October 31. o Amendments must be submitted in writing and are subject to approval by Enform. Submit a completed Action Plan, with supporting documents, no later than November 30 of the same year. After quality assurance review by Enform, the employer would have an opportunity to submit any revisions or supporting documents by December 31 of the current year. Completed Action Plans must achieve a score of at least 80% after Quality Assurance Review by Enform. If 80% is not achieved, the employer will be not eligible for an Action Plan the following year, and must complete another 3 year COR cycle before they are eligible. Enform Reviews Action Plan Application to determine approval. Reviews proposed Action Plan with objectives for approval. Reviews any proposed amendments to Action Plans for approval. Performs a Quality Assurance (QA) review on Action Plans. o Completed Acton Plan. o o Return completed Action Plan for revisions. Revised completed Action Plan. Advise employers not meeting quality standards or failing to meet the minimum 80%, that they are not eligible for Action Plans the following year Action Plan Approved December 15, 2015 Page 1 of 3

50 Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.10 Action Plan Approved December 15, 2015 Page 1 of 3

51 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.11 Safety Surveys Background The safety survey is a maintenance option that allows employers who have held a valid COR for four (4) or more consecutive years to use an approved safety survey and action planning process to meet their maintenance audit requirement over two (2) consecutive maintenance years. The safety survey differs from the other maintenance options as it sets specific requirements for both maintenance years. A safety survey is completed in the first maintenance year and based on the results, an action plan is developed to correct any deficiencies noted. In the second year the employer actively pursues and documents completion of the action plan items. Each Certifying Partner (CP) has the option to support or withdraw offering the safety survey as a maintenance option to their members. Policy For an employer to be considered for approval to perform a safety survey in lieu of a maintenance audit, they must: Have a current COR in good standing and have been active for a minimum of four (4) consecutive years Have achieved 90% or higher overall audit score in their last recertification audit The employer must apply to use of the safety survey process by March 31 of the first maintenance year after their last COR re-certification Safety surveys can only be used by employers in the regular COR program. PASE, SECOR and MECOR holders cannot use this process Enform must pre-approve an employer for use of a safety survey as a maintenance option The employer must use the Enform Safety Survey Audit Tool to conduct the safety survey. (Appendix Safety Survey Audit Tool) The Safety Survey Audit Tool must meet the government requires as outlined in Appendix Safety Survey Audit Tool Safety Surveys Approved: November 15, 2013 Page 1 of 5

52 The safety survey process must be utilized over two (2) successive maintenance years In the first maintenance year, an employer who has received Enform approval to use the safety survey as a maintenance option must: Conduct the survey (using (Appendix Safety Survey Audit Tool) prior to October 31, and ensure an acceptable number of employees from all levels have participated in the process. There must be a minimum 40% response or participation rate from the workforce. If the minimum response/participation date is not met, a 15-day grace period will be granted to the employer. If the minimum rate is still not achieved after this period, the survey cannot be used for COR maintenance, and the employer will have to complete a regular maintenance audit. The employer must next: Analyze the survey results to identify employee perceptions about the employer s health and safety systems. Develop a prioritized action plan based on the results using the form provided in Appendix 3.11: Safety Survey Action Plan. Electronically submit the action plan, safety survey summary reports, and verification of sampling numbers to Enform within 45 days of the data collection and no later than November 30. (An additional 15 day extension may be granted by Enform if requested prior to the expiry of the 45 days). A blank action plan document is not acceptable In the second maintenance year, the employer must: Actively pursue completion of the action plan items (using Appendix 3.11) from the previous year s safety survey. Provide an action plan update (submit Appendix 3.11 with progress outlined), or participate in a pulse check via meeting or conference call prior to March 31. Enform must be in receipt of the final version of the completed action plan (80% of the action items completed) by November 30 of the second maintenance year Employer s safety survey reports are archived by Enform for at least two years or until their next recertification audit Completing a safety survey in lieu of a maintenance audit may be used by an Enform certified auditor towards maintenance of auditor certification provided the following criterion has been met: The auditors was involved in all steps of the action plan process and signed off on the final report Safety Surveys Approved: November 15, 2013 Page 2 of 5

53 The final action plan submission meets Enform s quality assurance standards In year one, Enform will perform a QA Review (Appendix ) of the submitted action plan, safety survey summary reports, and sampling Completed information about the auditor and the audited organization must be submitted with the survey deliverables The sampling breakdown must include the total number of respondents, listed by level and department A summary of the survey results must identify employee perceptions of the organization s health and safety system A prioritized action plan (target dates and person accountable are assigned) addressing the issues identified through the analysis of survey results must be attached using Appendix 3.11: Safety Survey Action Plan Deliverables must be complete, organized and professional in appearance In year two, Enform will perform a QA review on deliverables submitted by November The action plan must verify that a minimum of 80% of the action items have been completed or are in progress Detailed and complete notes must be included to support the employer results for each action item listed Attached supporting documentation must be directly relevant to the specified action item, and provide good evidence of the stated degree of the item s completion Employers should avoid sending more documentation than what is strictly required to verify completion of each action item Deliverables must be complete, organized and professional in appearance. Procedure The employer: Maintenance Year 1 Submits a safety survey application to Enform using the safety survey form by March 31 of the calendar year. Receives approval from Enform to perform a safety survey in lieu of a maintenance audit. Conducts the survey prior to October 31 using the Enform approved tool (Appendix Safety Survey Audit Tool). Analyze the results to identify employee perceptions about the health and safety systems. If 40% participation has not been reached the employer can apply to Enform for a 15 day grace period. If at the end of the 15 day grace period, 40% participation has not been met the employer to notify Enform and the regular COR maintenance audit process to be followed Safety Surveys Approved: November 15, 2013 Page 3 of 5

54 If the 40% participation has been reached the employer develops a prioritized action plan based on the results using the form provided in Appendix 3.11: Safety Survey Action Plan. Electronically submits the action plan, safety survey summary reports, and verification of sampling numbers to Enform within 45 days of the data collection. Addresses any deficiencies or requests for additional information identified in the QA review within 30 days. Maintenance Year 2 Receives a reminder from Enform to be actively pursuing completion of action plan items and a request for an update on progress by March 31. o Provide an action plan update (submit appendix 3.11 with progress outlined), or participate in a pulse check via meeting or conference call. Electronically submits the final version of the completed action plan and deliverables to Enform by November 30. Addresses any deficiencies or requests for additional information identified in the QA review within 30 days. Enform will: Maintenance Year 1 Review and approve the safety survey application submitted by the employer. o Changes or additions to the safety survey may be requested by Enform. Provide follow up correspondence prior to each deadline to the employer to ensure timely and accurate submissions. o Survey should be completed by October 31. o o If 40% participation is not met a 15 day extension can be granted. Reminder of 45 day deadline for submission. Review any requests for 15 day extension based on whether more time is needed to achieve the 40% participation rate. Perform a QA Review of the action plan, safety survey summary reports, and verification of sampling numbers. Officially notify the employer and any applicable governing bodies of the successful (or non-successful) maintenance of COR. This notification includes requirements for Maintenance Year 2 activities. If not successful in passing QA review the employer is notified that they will need to follow the normal COR maintenance process Safety Surveys Approved: November 15, 2013 Page 4 of 5

55 Maintenance Year 2 Communicate requirements for second year maintenance information for the safety survey process. Provide follow up correspondence prior to each deadline to the employer to ensure timely and accurate submissions. o March 31 action plan update is required (submit appendix 3.11 with progress outlined), or participate in a pulse check via meeting or conference call. o November 30 final version of action plan with 80% completion is required to be electronically submitted. Perform a QA Review of the final version of the completed action plan and deliverables. This review includes feedback on the action plan report and deliverables and may include an opportunity to address any deficiencies or provide additional information if the final score falls below 80%. Officially notify the employer and any applicable governing bodies of the successful (or not successful) maintenance of COR. Communicate with the employer if deliverables do not meet quality standards and provide employer until December 31 to correct deficiencies or let the employer know that they will need to follow the regular COR maintenance process. Archive the completed action plan report for at least two years. Tracking Using imis activity Call log track employers who opt out, suspend or drop out of the safety survey process. Theses employers would follow the usual COR maintenance audit cycle. Using imis query functions track Safety Survey user recertification audit scores to identify any trends that may become apparent. Provide statistical reports to management in these areas. Approval Juliet Goodwin Manager, Safety Audits and Certifications 3.11 Safety Surveys Approved: November 15, 2013 Page 5 of 5

56 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 3.12 Overview: Additional Audit Types This section of the manual outlines policies and procedures for the process of an employer engaging in additional audit types such as site specific audits, limited scope and the PASE program with Enform. Eligibility requirements to participate are outlined as well as registration requirements for both the auditor and employer. Questions about specific policies or procedures should be directed to or option Overview: Additional Audit Types Approved: April 12, 2013

57 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.13 COR Audit Equivalency (PASE) Program Background Large employers with mature health and safety management systems may also have a wellestablished internal audit system. These employers may be eligible for a COR Audit Equivalency Program (known in Alberta as the Partnerships Audit Standard Equivalency or PASE). The PASE program allows employers to use their existing (or slightly modified) internal audit systems in place of the standard Enform COR audit instrument and process. Entrance into the PASE program is subject to approval from both Enform and the applicable governing bodies. In order to be eligible for PASE, employers would need to demonstrate sufficient alignment between their audit instruments and processes with the audit criteria established by the applicable governing bodies The PASE program allows large employers with mature health and safety management systems to participate and demonstrate leadership in the Enform COR program without the need to duplicate audit systems and processes. Policy Pre-approval phase: Employers must submit a formal application (Appendix and : PASE Application and Gap Analysis) for participation in the PASE program The application to be submitted by March 31 of the year in which the employer wishes to use the PASE program The application is reviewed to determine both the maturity of their health and safety management system as well as its alignment with COR standards and audit processes, including: Following a three year cycle in their audit process. A minimum of three years of successful use of their corporate health and safety audit system. The use of Enform certified auditors or have their auditors approved as corporate auditors in full alignment with 3.28 Use of Corporate Auditors COR Audit Equivalency (PASE) Program Approved: June 10, 2013 Page 1 of 4

58 The use of documentation, interview, and observation validation techniques and the use of representative interview and work site sampling in their audit instrument and must meet minimum standards. Description of the operation and the organizational chart. The employers audit plan and full audit cycle, including the interview and work site sampling plan (see below for audit cycle standards). The audit process, including the documentation of auditor notes, validation techniques, and scoring methodology. Gap Analysis phase: A proposal for the transfer of audit scoring from the employer s audit instrument to Enform s PASE gap analysis If an employer is accepted for consideration for the PASE program based on their application, Enform completes an initial gap analysis between their audit system and the applicable governing bodies audit standard The employer has until May 31 to provide any additional gap analysis information as a result of the gap analysis review Enform, with input from the applicable governing body, will complete the review by June 30 of the year in which an employer is seeking COR certification A gap analysis fee is applicable Once approved, the transfer of audit scoring from the employer s audit instrument to Enform s PASE gap analysis remains in place for subsequent audits unless there are significant changes in either the employer s audit instrument, or the applicable governing bodies audit standards If there are significant changes in either the employer s audit instrument, or the applicable governing bodies audit standards, the employer would need to have a new gap analysis completed In those cases where an employer adjusts their corporate audit instrument in order to address an identified gap, site audits already completed within the current audit cycle using the previous (deficient) audit instrument would need to have scoring adjusted for the deficient questions and the question included as part of the employer s final PASE gap analysis COR Audit Equivalency (PASE) Program Approved: June 10, 2013 Page 2 of 4

59 Final PASE Report phase: Audit scoring will be based on the previously approved proposal for the transfer of audit scoring The employer must use an approved Enform PASE auditor to transfer audit results from the employer s audit instrument to the Enform s PASE gap analysis Enform shall maintain a list of Enform certified auditors who are approved to conduct PASE audits Where an employer conducts multiple audits in the course of their annual audit cycle, the following standards apply to the audit cycle: The last day of on-site information gathering activities in the latest audit serves as the audit date/certification date for the final PASE gap analysis submission Only audits started and completed in the previous 12 month period prior to this audit date are eligible for inclusion for transfer to the gap analysis The cycle of work site sampling must adhere to the audit plan established in the application process Any audits used in a given annual audit cycle may not be re-applied to a subsequent audit cycle The final PASE gap analysis report, with completed scoring transfer, must be submitted to Enform within 90 days of the last day of on-site as defined above The final PASE gap analysis report must include: Auditor notes to justify the scoring for each question List of work sites covered, on-site information gathering dates for each, and sampling details from each site Enform shall perform a quality assurance review of the final PASE gap analysis report based on the agreed upon scoring transfer and the above standards A minimum audit score of 80% overall and 50% for each element is required for the employer to be eligible for COR certification Employers in the PASE program may perform an action plan in lieu of a maintenance audit to meet their COR maintenance requirements for the two years following the PASE audit Employers in the PASE program are exempt from the requirement that an employer must complete a full three year COR cycle to be eligible for an action plan in lieu of a maintenance audit COR Audit Equivalency (PASE) Program Approved: June 10, 2013 Page 3 of 4

60 Procedure The employer will: Contact Enform to enquire about their potential use of the PASE program. Review Enform s information package on the PASE program to determine their potential fit with the program. Submit a PASE application and if required any initial gap analysis information to Enform by March 31. Provide any information required by Enform and/or governing body to assist with process. If an initial PASE gap analysis is required, pay the applicable fees. Choose an approved PASE auditor to complete the final PASE gap analysis. Carry out their internal auditing program as per their documentation in the application, providing their PASE auditor with audit information required to complete a final PASE gap analysis report. The PASE auditor will: Register the audit as a PASE audit. Complete the final PASE gap analysis as per the audit protocol requirements including minimum requirement for awarding points. Submit a completed final PASE gap analysis report to Enform within 90 days of the last day onsite of the last audit included in the report. Enform will: Produce and provide an information package and advice on the PASE program for employers who may be a potential fit with the PASE program. Receive and review PASE applications. If required, complete the initial PASE gap analysis by June 30, after which there is: o An outline of how corporate audit scores are to be applied within the Enform PASE gap analysis by the PASE auditor. Provide the PASE auditor with the final results of the initial gap analysis. Perform a QA Review on the submitted final PASE gap analysis. Communicate results to the employer and auditor. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 3.13 COR Audit Equivalency (PASE) Program Approved: June 10, 2013 Page 4 of 4

61 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.14 Limited Scope Audit Background An employer whose audit does not meet Enform s scoring standards for certification may be eligible to apply for a limited scope audit. A limited scope audit is an audit that is conducted only on deficient areas of an employer s health and safety management system. Limited scope audits have two objectives: To produce focused and measureable improvements in an employer s health and safety management system. To offer an employer with minor system deficiencies the opportunity to achieve certification without repeating the entire audit process. To be eligible for a limited scope audit, the employer s original audit must achieve a minimum overall audit score of 70%. If as a result of the limited scope audit process the overall revised audit score meets the requirement of a minimum of 80% overall and 50% for each element, the employer is eligible for COR or SECOR certification/recertification as applicable. In the event that the original certification audit falls in one calendar year but the limited scope audit is not completed until the next, employers eligible for provincial refund programs may experience a delay in receiving their refund for the calendar year of the original audit. Given a successful outcome to their limited scope audit, however, they are eligible for a refund for that calendar year. Policy A limited scope audit may be offered to employers whose certification audit has achieved a minimum overall score of 70% and may include one or more elements scored below 50% The limited scope audit is available to all COR, MECOR, and SECOR certification audits conducted by an External auditor The limited scope audit is not applicable to SECOR self audits A limited scope audit is restricted to auditing the key deficiencies identified in an employer s health and safety management system during the certification audit Limited Scope Audit Approved: March 20, 2012 Page 1 of 4

62 The auditor who conducted the original audit must advise Enform as soon as possible if an opportunity exists for an employer to be considered for a limited scope audit It is imperative that the auditor fully complete the audit and submit a completed audit report to Enform for QA review in order to facilitate next steps in the limited scope audit process in a timely fashion Enform shall review the original certification audit report as soon as possible to determine if a limited scope audit is possible and contact the employer directly regarding this option The original certification audit score after Enform s audit QA review must be 70% or higher for a limited scope audit to be considered further If Enform grants the possibility of a limited scope audit: Enform shall work directly with the employer to determine the questions to be included within the scope of the audit The employer must submit a written plan that outlines how the deficiencies of the original certification audit will be corrected As part of the final approval process, Enform shall ensure the following: The original certification audit meets the minimal scoring criteria outlined above The deficiencies identified can be realistically corrected and corrective action implemented and validated through a limited scope audit within the timeframe remaining for the limited scope audit The scope of the proposed limited scope audit is sufficient to evaluate whether the deficiencies have been corrected The scope of the proposed limited scope audit has the potential to provide sufficient improvements in the audit score to secure certification The audit instrument to be used for limited scope audits must be the same as the one used in the original audit All scores for the original audit questions that are outside the scope of the audit remain the same A limited scope audit must be conducted by an Enform certified external auditor Enform and the employer will determine whether the limited scope audit should be completed by the original auditor The on site data gathering activities for the limited scope audit cannot exceed 45 days The limited scope audit must be completed and submitted to Enform within 135 days from the last day on site of the original audit The auditor must submit the completed limited scope audit report to Enform for audit QA review within 30 days of completing their onsite data gathering activities The limited scope audit report must contain an updated scoring summary sheet that includes the revised element scores and the re-calculated overall audit score Auditor notes must be submitted to support each question that has been rescored Limited Scope Audit Approved: March 20, 2012 Page 2 of 4

63 The audit recommendations as outlined in the original audit report must be updated to reflect the areas addressed through the limited scope audit process In order to pass, the revised audit score must be at least 80% overall and no less that 50% in each audit element and the limited scope audit report must pass QA review Enform will process the COR or SECOR certification using the last day on site of the original certification audit as the date of certification. Procedure The auditor on the original certification audit: Advises Enform as soon as possible if they encounter a scenario where an employer will fall just shy of the required audit score for certification and may be a candidate for a limited scope audit. Fully completes the audit as per the audit protocol requirements and submits a completed certification audit to Enform. Enform: Expedites the QA Review of an audit that has been flagged by as potentially eligible for a limited scope audit. Determines the eligibility of the employer for a limited scope audit. Informs the employer directly of the option to complete a limited scope audit. The employer, in consultation with Enform: Develops and submits a written plan to address the deficiencies identified in the audit. Enform: Reviews and makes a final determination of the eligibility of the employer for a limited scope audit in light of the employer s plan. Determines in conjunction with the employer which audit questions will make up the limited scope audit. o The audit questions selected must provide enough additional scoring potential to allow the employer to become certified (i.e., 80% overall; minimum 50% in each Element). Determines in conjunction with the employer who will conduct the limited scope audit. Documents these determinations and provides a written record to the employer and auditor carrying out the limited scope audit. The auditor assigned to the limited scope audit: Carries out the limited scope audit as per the audit plan within the required time frames. o These include a 45 day limit to on site data gathering activities, a 30 day limit on audit report writing after the last day of on site activities, and an overall limit of 135 days from the last day on site of the original audit Limited Scope Audit Approved: March 20, 2012 Page 3 of 4

64 Enform: Performs a QA Review on the limited scope audit. In the event of a successful limited scope audit, processes the certification of the employer using the last day on site of the original certification audit as the certification date. Informs the auditor and employer if the limited scope audit fails to result in certification. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.14 Limited Scope Audit Approved: March 20, 2012 Page 4 of 4

65 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 3.15 Site Specific Background An employer with multiple work sites which are classified under a single WCB account and industry may choose to conduct a site-specific audit. The COR will clearly identify the work site audited, however the resulting COR will not be eligible for the WCB's PIR incentive, unless all work sites included under that industry have also earned a COR. An employer may have two or more work sites classified under the same WCB account and industry code. The employer may choose to conduct a site-specific audit on one work site only. Should all governing body requirements be met, the resulting COR would include an identifier (typically the work site name) in the trade name field. The employer would not be eligible for a financial incentive unless all the work sites under that same WCB account and industry code also earned a COR. In some circumstances, the employer may request the governing body to split their operations into separate accounts to avoid the use of site-specific audits. If the separate accounts are granted, then the employer's CORs would cover the scope of each account, and make each site individually eligible for financial incentives. Interested employers should contact their governing body representative for more information. Policy Where an employer has two or more work sites classified under a single WCB account and industry code, a site-specific audit may be conducted. For sampling purposes, the audit must be representative of the work site audited, and follow all governing body sampling requirements The auditor must fully describe the employer s operations, including: a list of all work sites included under the employer s industry code. the specific work site included in the audit. When applying for the employer s COR through the online governing body systems, Enform will provide the details of the employer s site-specific audit, and list all work sites included under the same industry and account number Site Specific Approved May 21, 2013 Page 1 of 2

66 Once the audit has met all the governing body requirements, a site-specific COR will be issued. The COR will clearly identify the work site audited in the trade name field Employers must not include additional work sites outside the scope of their certification audit in their maintenance audits. Their other work site(s) (not covered by the original audit) must have either their own external audit(s) for certification, or be included with the original industry(s) code in a new, combined external certificate audit. Should an Employer Review be required of the employer s operations covered by the COR, the governing body will determine the scope of this review. Procedure The Enform certified auditor: Using the online registration system, registers the audit prior to the start of the audit. o o Indicates that the audit is site specific and provides a sampling plan (Appendix M). Notifies Enform of any changes to the approved audit plan during the audit process. Enform will: o o o o Review the audit registration and audit plan for the site specific audit to ensure governing body standards (including sampling standards) have been met by the site specific audit(s). Track all employers performing site-specific audits using the imis system. Track whether the entire operation is eligible for a financial incentive. Provide the details needed for the governing body on line system to recognize that the COR is for a specific site only. (BC does not support site-specific COR s) Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 3.15 Site Specific Approved May 21, 2013 Page 2 of 2

67 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.16 Group Audit of Related Employers Background There are cases where individually incorporated companies, each with their own WCB accounts, function as a singular entity in terms of ownership and control. Where these employers also share a single health and safety management system, they may be eligible to participate in a single, shared audit. It is important to note that while there may be efficiencies gained in a shared group audit, there is also a risk. A serious incident with any one of the employers could impact the COR status of all the related employers that were included in the original audit scope. If a group of related employers meet the criteria laid out in this policy, they may choose to be treated as the equivalent of a single employer with respect to their audit and audit requirements. For example, interview and work site sampling requirements would be based on the total combined operation. The initial audit for a group of related employers must always be a certification audit. Each individual employer in the group receives their own COR. In subsequent maintenance years, group members can pursue group or individual maintenance audits or options to maintain their individual COR certification. However, group members can never be added without a fresh external audit for certification. Policy In order to be eligible for a group audit of related employers, all related employers in the group must demonstrate they are: Incorporated legal entities Related through a common ownership, either on the basis of a common shareholder or through a subsidiary company structure. For publicly traded companies, the application would have to demonstrate at least one shareholder who has a significant ownership position in all of the group member companies Controlled together, through shared directors, senior management, or centralized reporting relationships Sharing a common health and safety management system that is actively used for all operations Group Audit of Related Employers Approved: March 26, 2012 Page 1 of 4

68 Related employers must apply to Enform for approval for a group audit as part of their audit registration (see Appendix J: Application for a Group Audit of Related Employers / PP103A) Audit registration will only proceed once the group audit approval is granted Enform shall inform all related employers of its decision to approve or deny the application for a group audit in writing Both the related employers application and Enform s formal response shall be kept on file for a minimum of three years for future reference The auditor must conduct the group audit of related employers as if they were a single combined entity. As such, the auditor: Must ensure that work site and interview sampling is representative of the overall operations of the whole group. The total number of required work sites visited and interviews conducted must be based on the total number of work sites and employees for the group as a whole Must provide additional information on the individual employers when submitting their audit for QA review. This includes: The total number of employees for each employer (as well as a breakdown of the corresponding number of managers, supervisors, and workers). The total number of employees interviewed for each employer (as well as a breakdown of the corresponding number of managers, supervisors, and workers). A further breakdown of sampling information for any individual employer that has multiple work sites or different business operations or processes Where a group audit of related employers for certification is successful (i.e., 80%+ overall, 50%+ for each audit element), each of the related employers are issued a separate COR in their own legal name with a common audit date and expiry date Maintenance requirements for related employers that have undergone a group audit for certification are as follows: All original group members may choose to conduct a single group audit for maintenance purposes or conduct a single maintenance option that applies to the group as a whole Some or all group members may conduct individual maintenance audits or maintenance options. In this case, all original group members must successfully fulfill their maintenance requirements either individually or as part of a group audit Group Audit of Related Employers Approved: March 26, 2012 Page 2 of 4

69 Enform shall confirm the status of the related employers during maintenance years. Any changes in ownership, control, or relation to the group shall be documented. Where applicable, these changes shall be registered with the appropriate governing body In the event that a group of related employers wishes to include additional employers in the group, they must undergo a new group audit for certification purposes In the event that an employer review must be conducted for any of related employers, Enform and/or the applicable governing body shall determine whether the review will include one, some, or all of the related employers. Procedure The related employers: Submit their application and required documentation for a group audit of related employers to Enform for approval in conjunction with their audit registration application. Enform: Reviews and approves or disapproves of the application for a group audit of related employers. As part of the approval process, Enform will establish that the related employers: o Are incorporated legal entities o Are related through common ownership o Are controlled together o Share a common health and safety management system that is actively used for all operations. Archives both the related employer s application and Enform s formal response for a minimum of three years. After approval for a group audit of related employers is granted, the auditor: Registers the group audit of related employers. Conducts the group audit as if the related employers were a single combined entity. This includes adhering to all required sampling requirements. o Work site and interview sampling is based on the total number of work sites and employees for all operations combined. o The sampling must be representative of the operations of the whole group Group Audit of Related Employers Approved: March 26, 2012 Page 3 of 4

70 Provides additional information unique to group audits of related employers, including: o The total number of employees for each employer with a corresponding breakdown by manager, supervisor, and worker. o The total number of employees interviewed for each employers (as well as corresponding breakdown by manager, supervisor, and worker). o A further breakdown of sampling information for any one of the employers that has multiple work sites or different business operations or processes. If a group audit of related employers for certification purposes is successful, Enform will either: Register both the related employers as a group and the individual employers with the relevant governing bodies to allow each to receive their own COR certificate in their own legal name (with a shared audit and expiry date). Provide individual COR certificates to each of the individual employers in their own legal name in those cases where Enform issues certificates apart from governing bodies. If the related employers are fulfilling maintenance requirements through (an) audit(s) or (an) option(s), the related employers: May opt for any one of the following three possibilities: o Conduct a group maintenance audit or engage in maintenance options as a singular group. o Conduct individual maintenance audits or options for each legal entity. o A combination of the above where some related employers fulfill maintenance requirements as a group and some opt for individual maintenance audits or options. Provide Enform with any information and requisite documentation regarding any changes in ownership, control, or relation to the group. If the related employers are fulfilling maintenance requirements through (an) audit(s) or (an) option(s), Enform will: Ensure all original related employers have fulfilled their maintenance requirements via a group or individual maintenance audit(s) or approved maintenance option(s). Forward any changes in any individual group member s ownership, control, or relation to the group to governing bodies as required. In the event an OSAR or verification audit is required for an employer certified as part of a group audit of related employers, the actual scope of this review will be negotiated with the appropriate governing bodies as required. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.16 Group Audit of Related Employers Approved: March 26, 2012 Page 4 of 4

71 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.17 Employers with Multiple WCB Accounts Background The following policy is applicable to employers with multiple WCB accounts and/or seeking COR certification in multiple provinces. Typically employers are granted only one WCB account per province. However, under certain circumstances, an employer may be issued multiple WCB accounts in one province. This may happen when an employer requests separate WCB accounts for their branch locations. Certain combinations of WCB industry classification codes may also require separate accounts for administrative purposes. As a national Certifying Partner, Enform has the ability to issue COR/SECOR in multiple provinces. Employers with operations in more than one province will have at least one WCB account per province. An employer with multiple WCB accounts can conduct one representative audit and receive separate CORs for each WCB account and/or province. Policy An employer (i.e., single legal entity) with multiple WCB accounts (either within one province or across multiple provinces) may either audit these accounts and/or provinces individually or they can elect to audit their accounts and/or provinces together If audited individually, each WCB account and/or province is managed independently through the COR audit and certification process If an employer elects to perform a single audit on more than one of their WCB accounts and/or provinces, the following standards apply: The audit must be representative of the overall operations. Interview and worksite sampling criteria are based on the overall operations. All WCB accounts and/or provinces must be represented in interview and worksite sampling The WCB accounts and/or provinces included in the audit (and all corresponding industry classification codes) must be listed during audit registration and in the audit report Employers with Multiple WCB Accounts Approved: March 15, 2012 Page 1 of 3

72 Upon successful completion of the audit, Enform and/or the relevant governing bodies shall issue separate COR certificates for each WCB account and/or province. All CORs issued will share a common audit and expiry date Maintenance audits must maintain the same audit scope as the certification audit. Additional WCB accounts and/or provinces may not be included in maintenance audits. Adding new WCB accounts and/or provinces to the audit scope requires a new, combined certification audit Enform shall include all the relevant WCB account numbers and industry classification codes covered by an audit scope when communicating with governing bodies regarding employers with multiple WCB accounts. Procedure Employers With Multiple WCB Accounts: Choose whether to audit their WCB accounts and/or provinces individually or collectively (or some combination of both if there are three or more accounts). If they are combining WCB accounts and/or provinces, this is communicated to their auditor(s). The Auditor: Notifies Enform of an employer s decision to manage multiple WCB accounts and/or provinces together when registering the audit. o All the WCB accounts and/or provinces that will be included in the audit scope must be listed in the audit registration. o Auditors may also confirm compliance with interview and worksite sampling criteria by submitting an audit plan to Enform. Performs a single audit on all WCB accounts and/or provinces included in the registered audit scope. o Interview and worksite sampling criteria are applied to the operations as a whole and all WCB accounts and/or provinces included are represented in the sampling. o The final audit report lists all WCB accounts and/or provinces included. Enform: Receives notification of an employer s decision to manage multiple WCB accounts together via the audit registration process. o If an audit plan has been submitted, Enform confirms compliance with interview and worksite sampling criteria has been met with the combined WCB accounts audit. Enform will inform auditors if they need to adjust their sampling. Upon receiving the audit report, as part of the audit QA process: o Ensures all WCB accounts and/or provinces included in the approved, registered audit scope are listed in the audit report. o Ensures interview and worksite sampling criteria have been met with the combined WCB accounts audit. o Ensures maintenance audits match the scope of the original certification audit with respect to WCB accounts covered Employers with Multiple WCB Accounts Approved: March 15, 2012 Page 2 of 3

73 Ensures that all communication with governing bodies concerning employers with multiple WCB accounts always provides a full listing of all WCB accounts that are subject to a single COR audit. o This includes listing multiple WCB accounts when registering successful audits with governing bodies. This is essential as each WCB account receives a separate COR. Maintains a list of all WCB accounts covered by a certification audit in the COR database to ensure this information is available for future maintenance audit QA reviews and communication with governing bodies. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.17 Employers with Multiple WCB Accounts Approved: March 15, 2012 Page 3 of 3

74 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.18 Employers with Multiple Industry Classifications Background Employers with operations that span multiple industries may be assigned more than one industry classification within their WCB account(s). These are known as Industry Code in Alberta; Classification Unit in British Columbia, and Industry Classification in Saskatchewan. Different parts of the employer s operations will function under different industry classifications. Usually these employers will simply perform one audit that encompasses all of the industries within their WCB account(s). However, employers also have the option to perform separate audits on only one or some other combination of industry classifications within a given WCB account. COR certification would then be limited to only those industry classifications that have been covered by the audit. Employers with multiple WCB accounts as well as multiple industry classifications within one or more of those accounts should also consult the policy for employers with multiple WCB accounts. Policy An employer with multiple industry classifications may audit these industries individually, collectively, or any combination of both For sampling purposes, the audit must be representative of all industries being audited, and follow Enform s interview and worksite sampling requirements If an employer audits all assigned industry classifications in their WCB account collectively, standard COR auditing practices apply This includes the requirement that all industry classifications are represented in their interview and worksite sampling All industry classifications must be listed in the audit report If an employer chooses to audit individual industry classifications or a subset of their total industry classifications, the following standards apply: The industry classifications included in the audit must be listed during audit registration and in the final audit report Interview sampling and work site sampling criteria are applied only to the operations represented by the industry classifications covered by the audit Employers with Multiple Industry Classifications Approved: March 21, 2012 Page 1 of 3

75 If a certification audit is successful, Enform and/or the relevant governing bodies shall apply COR certification only to the portion of the WCB account assigned the audited industry classifications. Maintenance audits must maintain the same audit scope as the certification audit. Additional industry classifications may not be included in maintenance audits. Adding new industry classifications to the audit scope requires a new, combined certification audit Enform shall include all the relevant industry classifications covered by an audit scope when communicating with governing bodies regarding employers with multiple industry classifications. Procedure Employers with multiple industry classifications: Choose whether to manage their operations individually or collectively with respect to COR auditing and certification (or some combination of both if there are three or more accounts). Their choice is communicated to their auditor(s). The Auditor: Notifies Enform of an employer s decision on managing multiple industry classifications when registering the audit. o All the industry classifications that will be included in the audit scope must be listed in the audit registration. o Auditors may also confirm compliance with interview and worksite sampling criteria by submitting an audit plan to Enform. Performs the audit on the operations covered by the industry classification(s) included in the registered audit scope. o Interview and worksite sampling criteria are applied to the operations represented by the registered industry classifications. o The final audit report lists all industry classifications included. Enform: Receives notification of an employer s decision to manage multiple industry classifications via the audit registration process. o If an audit plan has been submitted, Enform confirms compliance with interview and worksite sampling criteria has been met with the industry classifications included. Enform will inform auditors if they need to adjust their sampling. Upon receiving the audit report, as part of the audit QA process: o Ensures all industry classifications included in the approved, registered audit scope are listed in the audit report. o Ensures interview and worksite sampling criteria have been met with respect to the included industry classifications. o Ensures maintenance audits match the scope of the original certification audit with respect to industry classifications covered Employers with Multiple Industry Classifications Approved: March 21, 2012 Page 2 of 3

76 Ensures that all communication with governing bodies concerning employers with multiple industry classifications always provides a full listing of all industry classifications that are subject to a single COR audit. o This includes listing the specific industry classifications when registering successful audits with governing bodies. Maintains a list of all industry classifications covered by a certification audit in the COR database to ensure this information is available for future maintenance audit QA reviews and communication with governing bodies. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.18 Employers with Multiple Industry Classifications Approved: March 21, 2012 Page 3 of 3

77 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE 3.19 ROLL-UP AUDIT Background Large employers with multiple business operations, units, worksites, or WCB accounts may find it beneficial to conduct audits on each of these individually. Logistically, the sheer size of a company may warrant splitting the audit effort into several audits so that the audit can be done within a reasonable timeframe. Individual audits may also provide more insight into the health and safety performance of individual business units than a traditional company-wide audit. A roll-up audit allows these multiple individual audits to be submitted to Enform in the form of a single combined audit. Policy In order to be eligible for a roll-up audit, an employer must: Apply to Enform for approval to use the roll-up audit no later than June 30 of the calendar year in which they intend to perform the roll-up audit. The employer must provide all the information required for the Roll-Up Audit Application Form including auditor identification, worksite sampling, and interview sampling information (see Appendix H: Roll-Up Audit Forms). Depending on location of the audit, the provincial governing body may also be involved in the approval process Where applicable, develop an audit plan to include all employer work sites over a three year cycle and ensure that certification audits cover different work sites than those used in the previous certification audit. Where applicable, a representative sample of temporary or mobile works sites should also be included in the proposed audit plan The individual audits that contribute to the roll-up audit are subject to all Enform standards that apply to any regular certification or maintenance audit including: The use of the Enform Audit Protocol Work site and interview sampling requirements. Overall work site and interview sampling requirements are specified in the roll-up audit application. Any deviation from the approved application must receive approval from Enform Roll-Up Audit Approved: June 13, 2013 Page 1 of 3

78 Auditor certification. This includes the requirement that individual audits contributing to a certification roll-up audit are all carried out by external or approved corporate external auditors A time period of 45 days for information gathering Provision of recommendations for the specific unit audited Student auditors seeking auditor certification may participate in a roll-up audit under the following conditions: They must be under the supervision of a fully certified lead auditor The audit report they complete for the roll-up audit must function as their student certification audit. As such, student auditors must: Register their individual audit with Enform as a student certification audit. Submit a separate completed audit report for the operation or worksite(s) assigned to them for auditor certification purposes If the audit submitted for auditor certification purposes does not lead to auditor certification, the audit is invalidated for the purposes of the roll-up audit and must be repeated by a certified auditor The roll-up audit report must: Be completed and submitted within 60 days of the last day on site for the last audit conducted Only include individual audits conducted within the same calendar year as the roll-up audit Include sufficient individual audits such that the roll-up audit is representative of the employer s overall operations and aligns with the approved application for a roll-up audit. The roll-up audit report will provide justification and verification that work site and interview sampling standards have been met for the overall operation Be scored using Enform s Roll-Up Audit Scoring Worksheet which provides a consolidated score for: The individual audits overall scores. Each element and each question score weighted by percentage of employees represented by the individual audit Achieve the following scores if it is a certification audit: 70% or higher overall score for each individual audit. Minimum consolidated overall score of 80% or higher. No less than 50% in any consolidated element score Roll-Up Audit Approved: June 13, 2013 Page 2 of 3

79 Enform: Must conduct a full audit QA review on the submitted roll-up audit report May request and review any of the individual audit reports if necessary for a full evaluation of the roll-up audit results. The employer and/or lead auditor: Applies to Enform to conduct a roll-up audit in advance of the June 30 deadline for roll-up audit application submission. Provides all the necessary information as outlined above in their application submission. o See Appendix H: Roll-Up Audit Forms. Upon receiving the roll-up audit registration, Enform: Conducts a preliminary review of the roll-up application prior to submission to governing body (if applicable). Forwards the application to the appropriate governing body as required for approval. Approves or disapproved the application for a roll-up audit and communicates this decision to the employer. If approved, the auditor(s): Registers only the final rolled up audit report prior to submission. Conduct(s) the proposed individual audits within the calendar year and submit(s) the final roll-up audit report within 60 days of the last day on site for the last individual audit conducted. Submits any individual audit if requested by Enform. After roll-up audit submission, Enform: Provides an audit QA review on the roll-up audit that includes ensuring the roll-up audit has met the above policy s work site and interview sampling criteria. o Enform may request individual audits if required as part of the audit QA review process. When entering successful roll-up audit results into provincial COR registration systems, notation is made that the results are a roll-up audit in order to justify the 60 days allowance from last day on site to audit submission. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 3.19 Roll-Up Audit Approved: June 13, 2013 Page 3 of 3

80 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.20 Team Audit Purpose This procedure describes the circumstances under which audits would be performed by a team of auditors rather than just an individual. All auditors participating in the audit must adhere to the Auditor Code of Ethics. All team audits along with the supplemental sampling plan must be approved by Enform at time of audit registration. Scope Team audits are available under the COR and PASE Protocols. All team audits will be documented and reported using the ecompliance Audit Tool. A team audit may be performed under the following conditions: The employer is too large for one auditor to manage on their own. i.e. multiple sites, in excess of 500 employees. To provide an opportunity for multiple certified auditors to participate as a means of maintaining auditor status. To provide an opportunity for a student auditor to participate in an audit for qualification purposes. *Please note, only one student auditor is permitted in a team audit. The level of participation of the auditors in a team audit will be determine by: Audit type: certification or maintenance. Auditor status: certified, student, apprentice or corporate. (see Auditor Program for Corporate Auditor) Supporting Documents The following listed documents provide further information for Team Audits. Appendix M Sampling Plan this form is to document the sampling plans for all team audit members. EC Audit Tool (ecompliance Audit Tool) software application used to document and report COR audits. Roles & Responsibilities Certified External Auditor can perform all audit functions, including lead auditor for certification, and maintenance audits. Certified Internal Auditor can perform all audit functions, including lead auditor for maintenance audits. Audit Report Writer responsible for writing and submitting the final audit report Team Audit Approved: June 2, 2015 Page 1 of 4

81 Student Auditors can only actively participate in maintenance audits. They must take the role of a Lead Auditor for the area they are assigned, as this is their qualifying audit. This could include conducting a kick off and close out meeting, (if this was decided during the pre-audit meeting with the employer). Corporate auditors (once approved by Enform, this must be done before audit registration) can perform the same audit functions as a Certified Auditor. All team audit members must adhere to the following: Lead Auditor must: Be clearly identified. Provide a sampling plan for all team members. Participate in the data gathering activities for all three validation methods. Responsible for ensuring all information gathered from all team auditors is recorded in the audit report. This also includes results from any student audits. Responsible for designating a team member for report writing and ensuring the audit report is submitted within the accepted time or alternatively the lead auditor can also be the report writer. Responsible for all audit activities and audit timelines. Responsible for identifying all other team members and their roles. This information must be recorded on the audit reports. The information should note the areas or site(s) the members audited. Team Members will: Be assigned areas and sampling plans. Complete all their tasks as assigned within a designated time frame. Student Auditor must: Register the audit as a student audit for the purpose of qualification. Participate in all levels of audit activities. (pre and post-audit meetings, document review, observations and interviews etc.) (See Student Audit AT-230 for more details) Responsible for writing and submitting an audit report. Failure to submit the audit report could result in the invalidation of the entire team audit. Corporate Auditor must: Seek approval by Enform before audit registration Team Audit Approved: June 2, 2015 Page 2 of 4

82 ec-audit Tool The EC Audit Tool (ecompliance software) is used to document and report all on COR audits. Once all data is collected the team member files must be merged into one document. Before the merge occurs there are items that must be determined. These items will help save time and confusion for the audit report writer. This information has to do with the merge process within the EC Audit Tool. Procedure Before data is collected for the audit, discussing and determining the following will make report writing easier and faster. o Ensure everyone has the same base information on the company. Spelling and names of locations and other information must be the identical. If not, once merged duplication of information could occur. o Determine and agree how each auditor will record their field notes. (i.e. point form vs full sentences, excerpts from policy/procedure vs summarization etc). If all auditors on the team are certified, only one license key is required. Only one audit report is required. An additional license key is required, if a student auditor is one the team members. This is because the student auditor must submit their own completed audit report. The merge is completed in the same manner. The employer must determine who will assume the lead auditor position for the team audit. If Corporate Auditor/s are to be used, then an application must be made to Enform for approval. If approval is granted, then the Lead Auditor can start the audit registration process. a. The Lead Auditor will: Register the audit and indicate Team Audit. Also, be prepared to provide the following information. o Name of lead auditor and credentials o Name of all other auditor and credentials. o Indicate if any auditors are using the audit to maintain their certification. o If applicable the name of a student auditor and that they are using this for their qualification audit. NOTE: Only one Student Auditor is permitted. o A completed sampling plan is also required. o If there is a Student Auditor on the team, the Student Auditor must also register as they will need to write and submit their own report for qualification. b. Enform will: Review the application to ensure all the information required is present. o Check credentials for all auditors on team. o Review sampling plan. o If required, contact Lead Auditor for clarification. o Approve or disapprove team audit request. NOTE: Any changes to the team members or to the audit sampling plan once the audit is registered requires approval from Enform. c. The Lead Auditor will o Ensure the data collection portion of the audit is completed within the prescribed time frame. o Ensure the completed audit report is submitted on time to Enform for quality assurance review Team Audit Approved: June 2, 2015 Page 3 of 4

83 o Ensure any student involved submits their completed report on time to Enform for quality assurance review Approval d. Audit Report Writer o The report writer is responsible for re-submissions and revisions, unless there is extenuating circumstances that prohibits them from doing this. o Any student audits that do not meet the Enform quality assurance requirements that is also part of an overall team audit could result in the invalidation of the entire team audit Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.20 Team Audit Approved: June 2, 2015 Page 4 of 4

84 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.21 Injury Management/Return-to-Work Audit Background Injury Management/Return-to-Work (IM/RTW) programs are a way for employers to help injured workers stay at work or return to productive and safe employment as soon as physically possible after a work-related accident. Enform offers the IM/RTW audit to any employer with a current COR (or as part of an initial COR certification audit). In British Columbia, employers who successfully complete an IM/RTW audit are eligible to receive an additional 5% rebate on their previous year s WCB premiums. An employer with an existing COR may carry out their first IM/RTW external certifying audit at any time. Thereafter, the IM/RTW audit cycle will be aligned to match the existing COR audit cycle of certification and maintenance audits. Policy Employers that are eligible for an Injury Management/Return to Work (IM/RTW) audit must: Have 11 or more employees Have a current COR or be submitting their IM/RTW audit with a COR certification audit. When an IM/RTW audit is submitted along with a COR certification audit, the COR audit must successfully pass audit QA review for the IM/RTW audit to also succeed Auditors for IM/RTW audits must: Be Enform Certified Health and Safety Auditors Complete the Enform training on the IM/RTW protocol before performing any IM/RTW audit All IM/RTW audits must: Use Enform s IM/RTW audit protocol (see Appendix C: Injury Management/Return to Work Audit Protocol) Injury Management / Return-to-Work Audit Approved: March 21, 2012 Page 1 of 3

85 Cover the same operational scope as the COR certification audit In a multi-province audit, the IM/RTW audit may be applied to a single province (e.g., COR audit for BC and Alberta but IM/RTW audit for BC only). In this event, the same operation scope would be limited to the province in which the IM/RTW audit is applied Meet the Enform audit QA standards The interview and worksite sampling criteria for the IM/RTW audit follows that of the typical COR audit, with one important exception: A multi-provincial audit where the IM/RTW audit is only applied to one province may require additional interviews in that province to meet sampling criteria (see Appendix G: Sampling Requirements for IM/RTW audits) The IM/RTW program follows the three year cycle of the COR program, with a certification audit followed by up to two years of annual maintenance audits While the first IM/RTW audit for certification can be performed at any time for an employer with an existing COR, thereafter the IM/RTW audit must remain fully aligned with the regular COR cycle of certification and maintenance years An IM/RTW audit for certification purposes must: Be conducted by an external auditor Achieve 80% overall in the IM/RTW audit, with no less than 50% in any element The IM/RTW audit for maintenance purposes: May be conducted by an internal auditor. The internal auditor must complete Enform training on the IM/RTW audit as outlined above Does not have to meet the scoring criteria applied to certification audits. Procedure The auditor, at audit registration, indicates: The audit is a standalone IM/RTW audit (applicable only to a first time IM/RTW audit); or, The COR audit will include an IM/RTW audit. Enform: Ensures the employer seeking a standalone IM/RTW audit has an existing valid COR when approving the audit registration. Ensures the auditor performing an IM/RTW audit has received IM/RTW training. Approves and registers the IM/RTW audit accompanying COR certification or maintenance audits at the same time as the COR audit Injury Management / Return-to-Work Audit Approved: March 21, 2012 Page 2 of 3

86 The auditor: Follows the standard Enform COR audit procedures for IM/RTW audit completion and submission. Enform, upon receiving the IM/RTW audit: Performs an audit QA review on the IM/RTW audit. o IM/RTW audits are subject to the same time standards for addressing required QA issues as standard COR audits. Registers successful IM/RTW audits with the appropriate governing bodies where applicable. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.21 Injury Management / Return-to-Work Audit Approved: March 21, 2012 Page 3 of 3

87 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.23 Auditor Notes Background The Enform COR and SECOR audit protocols require auditors to provide a note to justify the score assigned for each audit question. This allows the auditor to explain their rationale for the scores assigned, verifies whether or not the auditor followed audit guidelines in completing the audit process and adds value to the audit report for the employer. The following policy and procedure both underscores the necessity of providing audit notes for each audit question and clarifies expectations with respect to these notes. This policy and procedure does not apply to SECOR assessors. Policy The auditor must write a note to justify the scoring of every audit question. These notes must: Reflect that the question guidelines have been followed Address each type of validation technique required to score the question Justify the score applied to each type of validation technique. In order to do so, the notes for questions where scoring is based on positive or negative indicators should: List and/or provide examples of positive indicators (if any points have been provided). List and/or provide examples of negative indicators (if any points have been withheld) As appropriate and wherever possible, include company specific examples Be consistent with the notes and score awarded for other related questions Auditor notes must be original and specific to the audited employer s health and safety systems during the period of the current audit Auditor notes in the final audit report submitted to Enform and the employer should not include the following: Any direct reference to a specific employee Personal opinions of the auditor Auditor Notes Approved: March 27, 2013 Page 1 of 2

88 Simple restatement of the audit question as the only justification for the score awarded Contradictory information Boilerplated or templated notes. Boilerplated notes are notes that are copied from notes prepared for previous employers or audit reports, which may or may not have been altered. Templated notes are pre-crafted, ready-made notes that are used as a template, which may or may not have been altered, and form the basis of the auditor s current report. Procedure The auditor: Includes auditor notes that are in compliance with the above policy when submitting their final audit report. The Enform audit QA reviewer: Ensures compliance with the above auditor notes policy in the course of their audit QA review. May provide specific and/or general feedback to the auditor to correct or improve auditor notes as part of the audit QA review cycle. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 3.23 Auditor Notes Approved: March 27, 2013 Page 2 of 2

89 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.24 Audit Sampling Background It is important that the auditor conducts employee interviews and work site sampling that sufficiently represent the employer s workforce and operations covered by the scope of the audit. All audits completed for certification or maintenance of COR, SECOR or MECOR must be completed using the same basic auditing principles and standards in order to ensure the integrity of the audit process and the credibility of audit results. The following policy and procedure sets out the factors that must be considered in developing representative samples for audit interviews and work site sampling. This also stipulates minimum interview and work site sampling standards required to meet Enform s audit standards. Policy When selecting their interview sample, auditors must use representative sampling that reflects both the size and complexity of the organization being audited. Interviewees should not be selected based on availability or knowledge of the health and safety systems. To be representative, the interview sample must include employees from: All departments All shifts All employee levels (include a cross section from every staffing level including senior and middle management, supervisors, and workers, including contract, part time, and casual employees) All types of work (if the audit covers multiple provinces, WCB accounts and/or industry codes or classification units, include personnel from each of these) A representative number of work sites (see ) Company history (if the company has been through a recent reorganization or restructuring, include both old and new parts of the company) The minimum number of interviews that must be conducted is determined by an employer s total number of employees The minimum number of interviews based on the total number of employees can be found in Appendix F1: Audit Work Site and Interview Sampling Tables The auditor may be required to exceed the minimum number of interviews based on the total number of employees in order to meet the sampling requirements listed in Audit Sampling Approved: March 23, 2017 Page 1 of 5

90 The choice of which employees to interview is to be selected by the auditor prior to starting the audit All interviews must be carried out face-to-face by the auditor The use of interview questionnaires is not approved for Enform audits Telephone interviews may be considered only in extenuating circumstances (i.e. senior management personnel or highly specialized individuals are unavailable due to their work location during the course of the audit) The use of telephone interviews requires prior approval from Enform and the rationale for these exceptions need to be noted in the audit report Telephone interviews cannot be used as a substitute for a work site visit required to meet representative work site sampling The auditor should provide an audit plan during audit registration that includes a proposed interview sampling plan if auditing large and/or complex operations Enform will provide guidance to an auditor that submits an audit plan to ensure interview requirements are fully understood in advance of the audit Work site sampling must be representative of the overall operations covered by the scope of the audit. To determine representative work site sampling auditors must, as a minimum, consider the following criteria (see Appendix F for more detail): All activities under applicable WCB account(s) and industry code(s) or classification unit(s) Work site size differences The diversity of work conditions from one work site to another The location of the work sites The minimum number of work sites to be sampled as required by the governing bodies For multi-jurisdictional audits, work site sampling must cover a sampling of all provinces Employers with 3 to 30 fixed manned sites where employees are stationed on an ongoing basis must include all work sites as part of the audit scope over the course of the 3-year audit cycle Unless they are including all work sites inside the scope of their certification audit, and employer with more than 2 sites cannot use the same combination of sites for COR certification that were audited for the previous certification Audit Sampling Approved: March 23, 2017 Page 2 of 5

91 An employer with more than 2 work sites must include their main office or shop in each province as part of the work site sample every year. If an employer has 2 main offices/shops in a province, each main site should be included as part of the audit scope every other audit year If an employer s audit scope is larger than 30 sites, the employer/auditor must consult with Enform to determine the representative sampling by completing an audit plan. Enform may consult with the governing bodies to determine an appropriate sampling methodology for these employers In cases where the activities (conditions, location, type of work, work site size, number of employees, etc.) inside the employer s scope of operations are not consistent across sites, multi-site audits may require a sampling of more than the minimum number of work sites to be representative. Employers/auditors should consult Enform to determine adequate work site selection Employers that have employees perform work at field work sites; operate mobile equipment; and motor vehicle fleets, including commercial vehicles, must consider these as work sites and have these accounted for under the work site totals Where there is potential for more than 30 of these types of work sites the auditor must contact Enform for guidance and submit an audit plan Employer-owned work sites which may be intermittently visited/serviced by workers, but employees are not stationed there on an on-going basis must be included in the scope of the audit if applicable to the WCB account and industry code(s) or classification unit(s) being audited; however, there is no minimum sampling requirement for these work sites. Employers/auditors must determine appropriate sampling through consultation with Enform to complete an audit plan to determine a reasonable sample Worker home office sites are not considered to be work sites unless they are owned by the employer. A representative sample of workers who work from their own home office sites should, however, be included in the interview sampling Mobile equipment and vehicles are not considered work sites for the purposes of representative site sampling. They are not subject to minimum site-sampling requirements, but representative sampling of operators should be included in the interview process Special sampling guidelines apply where staffing agencies (under industry codes and 86911) provide temporary labour for another employer s operation. (See Appendix F2.) Site observations must be conducted where possible, but are not subject to minimum site-sampling requirements. Sites should be selected based on level of risk Temporary employees of a staffing agency that are sent to off-site locations to work for another employer should be categorized separately inside the auditor s sampling table (i.e. the total number of temporary employees and the number of sampled temporary employees should be listed as a separate category of employee inside the auditor s sampling table) Audit Sampling Approved: March 23, 2017 Page 3 of 5

92 Interview sampling for these temporary staffing agency employees is calculated in addition to the minimum required for the sampling of permanent staffing agency employees (as per Appendix F2). The number of temporary employees sampled must be at least equivalent to the number of permanent agency employees sampled Interviews do not have to be held on the work site Interviews of temporary workers will focus on orientations, emergency response, hazard assessment, job-specific training provided, right to refuse unsafe work, PPE, injury reporting, MSDS and WHMIS. A separate set of interview questions may be provided. Any findings specific to temporary staffing agency workers must be documented inside auditor notes The auditor should provide an audit plan during audit registration that includes a proposed work site sampling plan if auditing employers with more than 30 sites and/or complex operations Enform will work with any auditor that submits an audit plan to ensure work site requirements are fully understood and in advance of the audit The auditor must report and demonstrate compliance with the above sampling standards by tracking their interviews and all work sites (visited and not visited) within the Enform COR Audit Protocol Enform will confirm compliance with the interview and work site sampling standards through the audit quality assurance (QA) review process. Procedure The auditor: An audit cannot pass Enform s audit QA review process if it does not comply with the interview and work site sampling standards. Conducts sufficient employee interviews and work site sampling as per the above policy and procedure. Contacts Enform for guidance and submits an audit plan prior to the start of the audit, as required in the above policy and procedure. Communicates with Enform any changes to the approved audit plan during the course of the audit. Includes auditor notes that are in compliance with the above policy when submitting their final audit report. Also, if an audit plan was approved this should be noted within the final audit report. Enform will: Provides the Appendix F1: Audit Worksite and Interview Sampling Tables and Appendix F2: Auditing Staffing Agencies to auditors through the Enform website and as requested. Provides guidance to auditors that submit an audit plan for interview and work site sampling, as required in the above policy and procedure Audit Sampling Approved: March 23, 2017 Page 4 of 5

93 Approves completed audit plans prior to approving an audit registration, as required in the above policy and procedure. Ensures compliance with the above auditor notes policy in the course of their audit QA review. May provide specific and/or general feedback to the auditor to correct or improve auditor notes as part of the audit QA review cycle. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.24 Audit Sampling Approved: March 23, 2017 Page 5 of 5

94 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.26 Extending Audit Scope to Out-of-Province Temporary Work Sites Background In the oil and gas industry, it is not uncommon for employers in one province to have temporary work sites and/or utilize mobile equipment in other provinces. It may even be the case that an employer may only have an administrative office in one province and all their active work sites in another. This policy is designed to make it possible for employers who find themselves in a situation where they do not have sufficient or any work sites in their home province to use out-ofprovince work to maintain their COR certification. Employers using this option are required to provide Enform with a report detailing their out-ofprovince health and safety performance for the twelve months preceding the audit. It is an expectation that prior to considering this option that the employer and auditor have exhausted all re-planning options of the audit timeframe and ruled out that work sites will become available in the province within the calendar year. Policy The use of out-of-province temporary work sites in an audit scope is to accommodate situations where there is legitimately no active work sites throughout the course of a calendar year in a particular province This option is not intended to eliminate including more than one province in their audit for the sake of convenience For an employer to be eligible to include out-of-province temporary work sites in their audit scope, they must submit, in writing, an application (Appendix I: Employer Report of Health and Safety Performance (for Out-of-Province Work Sites)) to Enform to use out-ofprovince temporary work sites in their audit scope. The application must: Be submitted prior to registering or starting the audit Include an audit plan outlining the work sites and interview sampling to be conducted for the current year, and identify any temporary work sites operating out-of-province In maintenance years, the application must include sufficient details of the scope of the last certification audit to allow comparison with proposed audit sampling plan Include a completed report of the employer s health and safety performance over the twelve months preceding the audit Extending Audit Scope to Out-of-Province Temporary Work Sites Approved: May 23, 2013 Page 1 of 4

95 Approval to include out-of-province temporary work sites in the audit scope is valid only for the current audit year For approval to conduct an audit that includes out-of-province temporary work sites, an employer must meet the following criteria: The employer must maintain an office and operations in the province they are seeking certification If applying during a maintenance year, demonstrate that the current audit will not result in a significantly different audit scope when compared to their original certification audit Self-report to Enform on their health and safety performance over the previous twelve months in their out-of-province operations Self-report any fatality, serious injury, or violation of a local health and safety violation to Enform within 30 days. Failure to fulfill this requirement will result in the cancellation of an employer s COR In maintenance years, Enform will consider the following to determine whether the audit scope described in the application will result in significant change from the scope of the original certification audit: The change is considered to be a normal year-to-year business fluctuation (e.g. expansion or contraction of business), the audit may be approved If the change is considered to be a fundamental change of operations, a new certification audit may be required to encompass the revised scope of operations Audits must meet the following criteria for interview and work site sampling: The description of operations must include all fixed and temporary work sites (including mobile equipment) included in the current audit scope (whether included in the audit sample or not) Justification of the interview sampling must include a breakdown by level for all employees at the work sites described above, and a corresponding breakdown of the interview sampling Sampling must include a representative sample of fixed work sites, including the administration or head office in the province where COR is being sought Sampling must include a representative sample of temporary work sites both in and out of the province where COR is being sought Extending Audit Scope to Out-of-Province Temporary Work Sites Approved: May 23, 2013 Page 2 of 4

96 The application must include a report on the employer s health and safety performance that meets the following criteria: The report must cover the twelve months preceding the audit date The report must include all operations in jurisdictions included in the audit The report must include the following information: the details of any fatalities, serious injuries or serious incidents that occurred, including jurisdiction, date, location, a brief description of the incident/injury, and whether the worker was hospitalized for 2 or more days, and the details of any violations of occupational health and safety legislation, including the date, location, jurisdiction, brief description, orders written (if applicable), penalties imposed, and details of charges or convictions The out-of-province application must be signed by the president, a director, or a senior office of the employer Enform must forward a copy of the out-of-province application to the governing body Temporary work sites may include such activities as: Oilfield drilling Oilfield servicing with mobile equipment Other operations which are temporary and/or utilize mobile equipment Employers approved to include out-of-province work sites in their audit, may be subject to a review by the governing body should fatalities, serious injuries or incidents, and/or violations of local occupational health and safety legislation occur on their out-of-province work sites associated with their COR In the event of a fatality or serious injury on an out-of-province site, the employer must contact Enform within 30 days with the details. Enform will forward this information to the applicable governing body. Procedure The auditor: Registers the audit using the online system prior to the audit starting. Applies to include out-of-province work sites via the Appendix I: Employer Report of Health and Safety Performance (for Out-of-Province Work Sites). Includes the following in their application: o A proposed outline of all work sites and interviewing sampling and details of temporary work sites. o In maintenance years, sufficient details of the scope of the last certification audit to allow comparison with proposed audit sampling plan. Receives approval prior to starting the audit Extending Audit Scope to Out-of-Province Temporary Work Sites Approved: May 23, 2013 Page 3 of 4

97 Enform will: Review the registration and application for out-of-province work (Appendix I) to ensure all criteria are met. Work with the governing body for approval. Communicate the results with auditor and employer. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 3.26 Extending Audit Scope to Out-of-Province Temporary Work Sites Approved: May 23, 2013 Page 4 of 4

98 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.27 Out-of-Province COR Background There may be situations in which companies require a COR in an outside province as a precondition to bid work or as a contracting requirement. In this scenario, employers situated outside that province that want to provide contract services are in a position where they require a COR but do not, as yet, have any work sites within that province to audit. There are also cases where employers in one province routinely operate mobile equipment or temporary work sites in another province and would benefit from having a COR within that province. For the purposes of this policy, temporary work sites may include such activities as: Oil field drilling. Oil field servicing with mobile equipment. Other operations which are temporary and/or utilize mobile equipment. The out-of-province COR is an option for out-of-province employers to demonstrate effective health and safety management systems in order to meet provincial COR requirements. Employers earning an out-of-province COR will be issued a one-year COR. Policy To be eligible for a COR, an out of province employer must: Make written application to Enform prior to completing the audit (Appendix I: Employer Report of Health and Safety Performance (for Out-of-Province Work Sites)) Successfully complete all applicable health and safety training requirements (if applicable) Use an Enform certified external auditor and the Enform COR audit protocol Comply with all applicable Enform audit standards Work site sampling requirements are based on out-of province operations Out-of-province employers are restricted to a one-year COR Out-of-Province COR Approved: May 1, 2013 Page 1 of 3

99 The out-of-province application (Appendix I) must include a report of the employer s health and safety performance in their home province. The report must meet the following criteria: The report must cover the twelve months preceding the audit date The report must include all operations in jurisdictions included in the audit The report must include the following information: the details of any fatalities, serious injuries or serious incidents that occurred, including jurisdiction, date, location, a brief description of the incident/injury, and whether the worker was hospitalized for 2 or more days, and the details of any violations of occupational health and safety legislation, including the date, location, jurisdiction, brief description, orders written (if applicable), penalties imposed, and details of charges or convictions The out-of-province application must be signed by the president, a direction, or a senior office of the employer Enform must forward a copy of the out-of-province application to the governing bodies Out-of-province employers may be subject to a an employer review by the governing bodies should fatalities, serious injuries or incidents, and/or violations of local occupational health and safety legislation occur on their out-of-province work sites associated with the out-of-province COR In the event of a fatality or serious injury on an out-of-province site, the employer must contact Enform within 30 days with the details. Enform will forward this information to the applicable governing body Employers with an out-of-province COR that establish a permanent office location in the province in which they hold an out-of-province COR: Are no longer considered out-of-province COR holders Must include the newly established location(s) within the scope of their next scheduled audit May be required to perform a new certification audit if the newly established operations differ significantly from the scope of their original certification audit Employers with an out-of-province COR that establish or already have temporary work sites or operate mobile equipment in the province in which they hold an out-of-province COR must adhere to the following requirements. The employers must: Meet the self-reporting requirements outlined above Out-of-Province COR Approved: May 1, 2013 Page 2 of 3

100 Procedure Establish and maintain a WCB account in the province in which they hold an out-of-province COR Ensure their health and safety management system covers workers both in their home province and in the province in which they hold an out-of-province COR Provide an audit scope that encompasses temporary work site and/or mobile equipment employees both inside and outside the province in which they hold an out-of-province COR. The Enform certified auditor: Using the online registration system, registers the audit prior to the start of the audit. Requests in writing via corinfo@enform.ca to use the out-of-province policy and outline why. If preliminary approval is provided by Enform, the auditor works with the client to complete Appendix I and includes a proposed outline of all work sites and interviewing sampling and details of temporary work sites (especially if the employer has existing temporary work sites in the province in which they are seeking an out-of-province COR). The employer: Completes and submits the out-of-province application (Appendix I) must include a report of the employer s health and safety performance in their home province. Enform will: Discuss with the auditor the criteria surrounding using this policy to determine if the Employer would meet the criteria. Have the auditor work with the employer to complete the Appendix I, include an employer report of health and safety performance for work sites out of the province included in the audit scope. Review any additional information required for the out-of-province COR. Forward these, as required, to the governing bodies. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 3.26 Out-of-Province COR Approved: May 1, 2013 Page 3 of 3

101 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.28 Use of Corporate Auditors Background Large employers with a complex organization and a well-developed, internal corporate auditing system may use their internal corporate auditors to complete a certification audit if they can demonstrate their independence. For internal corporate auditors to be considered for certification audits, they must remain independent of the management for the departments or sites they are auditing. Furthermore, they cannot carry responsibility for the health and safety performance of those operations. The use of internal corporate auditors for any employer is subject to approval by both Enform and the appropriate governing bodies as required. Policy In order to be eligible for the use of corporate auditors for certification/recertification audits employers must: Have over 500 employees and multiple work sites Apply to Enform (and any required governing bodies via Enform) for approval Use the Enform audit protocol or have their audit protocol approved by Enform and, the appropriate governing body, as required Have their corporate auditors certified by Enform or have their existing auditor credentials approved by Enform and the appropriate governing body as required Demonstrate the independence of the corporate auditor(s) from the operation or work site being audited. To fulfill this criterion: Auditors must not report to the management of the operation, work site, or facility they are auditing. Auditors must not be involved in the development and implementation of the health and safety management system at the operation, work site, or facility they are auditing. Auditors must not be held accountable for the effectiveness of the health and safety management system of the operation they are auditing. In the event of a team audit, all members of the team must meet this standard of independence Use of Corporate Auditors Approved: March 27, 2012 Page 1 of 3

102 Employers who wish to use corporate auditors for their certification audit must submit a written application and supporting documentation for review (see Appendix K: Application for an Employer to use Corporate Auditors).This application must include: Auditor information, including: Full list of auditors to be considered. Auditors Enform certification numbers (if applicable). Auditors job titles, their reporting unit/work group, and a description of their responsibilities for health and safety within the organization Organizational information, including: Organizational structure. Reporting relationships between various operations, work sites, or facilities and between these and corporate auditing Enform, in consultation with relevant governing bodies (if applicable), shall approve or reject corporate auditors for certification/recertification audits based on the application provided by the employer Enform shall maintain a copy of the employer s application and supporting documentation until the next certification audit or until the COR certification expires The employer must seek re-approval for each subsequent certification audit. Procedure The Employer: Applies to Enform to use internal corporate auditors in advance of registering their certification/recertification audit. o See Appendix K1: Application for an Employer to use Corporate Auditors Provides the necessary documentation along with a completed application that demonstrates the independence of their corporate auditors for the proposed certification audit and full compliance with the above policy standards. Upon receiving the application for approval, Enform: Reviews the application and supporting documentation to ensure compliance with the above policy standards. If required, Enform forwards approved applications and all supporting documentation to the relevant governing body for approval. Enform communicates its decision, or the decision reached in consultation with the relevant governing body, to the employer. If approved, Enform maintains a copy of the employer s application and supporting documentation until the employer s next certification audit or the COR certification expires Use of Corporate Auditors Approved: March 27, 2012 Page 2 of 3

103 Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.28 Use of Corporate Auditors Approved: March 27, 2012 Page 3 of 3

104 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.29 COR Audit Quality Assurance Review Background COR audit reports must pass a quality assurance (QA) review by Enform before they can be approved for the purposes of COR certification or maintenance. The audit QA review ensures that the reports meet all applicable Enform and provincial standards for completeness of information, adequate and representative sampling, and the correct application of the auditing process. Since there are some important difference in the COR and SECOR QA review process, these have been addressed as distinct policies. Policy Audit reports completed for the purpose of certification or maintenance of a COR, or Enform Health and Safety Auditor Certification must successfully pass an Enform audit quality assurance (QA) review before the audit report can be approved Enform s COR Audit QA Review Form is the instrument that shall be used to evaluate the quality of the audit report (see Appendix N: COR Audit Quality Assurance [QA] Review Form). Where required, this audit QA review form has been formally approved by the applicable governing bodies. The Enform COR Audit QA Review Form approved by the relevant governing bodies shall only be changed in consultation with those governing bodies To successfully pass an Enform QA review, an audit report must achieve a minimum score of 80% overall using the Enform COR Audit QA Review Form and 100% on all critical criteria An Enform audit reviewer shall use the COR Audit QA Review Form to ensure: Critical data concerning the employer, auditor, and audit have been included in the audit report. This includes: Employer name, address, contact name, phone number, fax number, and WCB account number(s) and industry code(s) covered by the audit Auditor name, phone number, and certification number Audit start date and last date on site Type of audit (e.g., COR certification; COR maintenance; Six-Month COR; auditor certification, etc.) 3.29 COR Audit Quality Assurance Review Approved: March 26, 2012 Page 1 of 4

105 Interview sampling standards have been met. Specifically: Auditors have provided a detailed breakdown of the employer s total workforce including major departments, organizational level, and status and how many were interviewed from each category as well as ensuring all WCB accounts and industry codes were represented. Auditors have provided a justification for their interview sampling Worksite sampling standards have been met. Specifically: Auditors have provided a detailed breakdown of all of the employer s worksites within the scope of the audit, the type of activities conducted on the site and whether or not they were visited. Auditors have confirmed compliance with all standards related to worksite sampling The proper auditing process was followed and the appropriate protocol was used correctly and that the auditor has produced a comprehensive and accurate audit report for the employer. The Enform COR Audit QA Review Form divides criteria in this category into two classes: Critical criteria: Any audit shortcomings on these criteria must be corrected by the auditor before the audit report is approved. These criteria include: o o o o o o o Auditor notes must accurately answer the question according to the instructions. Audit instructions must be applied correctly in scoring each question. Audit scores must be fully justified through the use of company specific auditor notes, without contradiction between notes and scoring. Contradictions between scoring, auditor notes, and/or recommendations within elements should not be found. Contradictions between findings from one element to another should not be found. Scores must be accurately calculated. The completed audit report must be professional in appearance with minimal grammar or spelling errors. Criteria that are scored but may not require correction if the overall review score meets the 80% minimum required score. These criteria include: o o o Validation techniques (documentation review, interview, observation) must be applied according to the audit guidelines. Reports must include a listing of health and safety management system strengths, supported by company specific auditor notes, and presented according to the Enform audit report format. Reports must include a list of company specific recommendations for improvement, supported by auditor notes and scoring, and presented according to the Enform audit report format COR Audit Quality Assurance Review Approved: March 26, 2012 Page 2 of 4

106 Enform shall provide feedback to auditors as part of the audit QA review process. This feedback will outline the strengths of their report, identify required corrections, and, as applicable, recommend opportunities for improvement to report quality Enform shall provide auditors the opportunity to address any audit deficiencies identified in the audit QA review process. There are two critical time deadlines associated with the audit correction process: Auditors must return a corrected audit within 30 days of receiving their audit QA review feedback The total timeline permitted for the audit QA review/audit correction process is 90 days from the auditors receiving their first audit QA review feedback Upon successful completion of the audit QA review process, Enform shall inform both the employer and the auditor in writing. In this communication, Enform shall also: Inform the employer that they are to expect a final, approved version of the audit from their auditor Inform the auditor they are responsible to provide the employer with a final, approved version of the audit Enform shall not accept audit reports for certification or maintenance of certification purposes that fail to meet the quality standards applied in the audit QA review. Procedure The auditor: Both the employer and auditor will be informed of a decision by Enform to reject an audit report that fails to pass the Enform audit QA review process. Completes the audit in accordance with Enform audit standards. Submits their completed audit report to Enform within the required timelines Enform: The audit is assigned to an audit reviewer and this individual reviews the audit report using the appropriate Enform Audit Quality Assurance (QA) Review Form. If any critical criteria issues are identified in the audit QA review or the overall score of the QA review falls below 80%, Enform shall inform the auditor of the audit QA results and identify what corrections need to be made. If the audit report successfully passes the audit QA review process and receives approval, Enform shall: o Inform the employer in writing that the audit has passed audit QA review and that they should expect a final, approved version of the audit from the auditor. o Inform the auditor of the approval and remind them of their responsibility to provide the employer with a final, approved version of the audit. o Begin processing the audit results for certification or maintenance purposes COR Audit Quality Assurance Review Approved: March 26, 2012 Page 3 of 4

107 In the event that the audit report requires corrections before it can be approved: The auditor has 30 days to address all issues identified by Enform in the Audit QA Review Form and resubmit the audit for a second audit QA review. If the corrections are adequate and all critical criteria issues are addressed and the overall score of the audit QA review now meets the 80%/100% threshold, the audit report is processed as above. If the corrections are insufficient, additional rounds of corrections may be required. The total time allowed for all correction cycles is 90 days from the date the auditor received the first round of audit QA review feedback. In the event that an audit report that fails to meet the QA standard is not corrected to meet the standard within the timeframes outlined in the policy: The audit is rejected as insufficient for certification or maintenance purposes. o Both the auditor and the employer will be informed of this decision. o A fresh audit will need to be conducted if the employer wishes to achieve certification, recertification or maintenance of their COR. Approval Paula M.A. Campkin, MBA, CRSP Manager, Safety Audits and Certifications 3.29 COR Audit Quality Assurance Review Approved: March 26, 2012 Page 4 of 4

108 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.30 SECOR Assessment Quality Assurance Review Background SECOR audit reports completed by a SECOR assessor must pass a quality assurance (QA) review by Enform before they can be approved for the purposes of SECOR certification or maintenance. The audit QA review ensures that the reports meet all applicable Enform and provincial SECOR audit standards. Policy SECOR audit reports completed for the purpose of SECOR certification or maintenance must successfully pass an Enform audit quality assurance (QA) review before the audit report can be approved A standardized SECOR assessment QA review form shall be used to evaluate the quality of the assessment report (see Appendix O1: SECOR Audit Quality Assurance (QA) Review Form and Appendix O1: SECOR Audit Quality Assurance (QA) Review Recommended Practice) Where required, the SECOR assessment QA review forms have been approved by the applicable governing bodies Upon receipt of a SECOR audit, Enform staff shall ensure the employer and the SECOR assessor have met the Enform SECOR training requirements An Enform audit reviewer shall use the appropriate SECOR assessment QA review form to ensure: Critical data concerning the employer, SECOR assessor, and assessment have been included in the audit report. This includes: Employer name, address, contact name, phone number, fax number, and . SECOR assessor name, phone number, and . WCB account number(s) and industry code(s) covered by the assessment. Assessment start date and last date on site. Employer profile and number of employees. SECOR assessor sign-off When performing an assessment QA review on a SECOR audit report completed by a company SECOR assessor, the audit reviewer shall ensure they are applying the recommended practice as outlined in Appendix O2: SECOR Assessment QA review Recommended Practice SECOR Assessment Quality Assurance Review Approved: March 24, 2017 Page 1 of 4

109 When performing an assessment QA review on a SECOR audit report completed by a company SECOR assessor, the audit reviewer shall ensure all questions in the audit have been sufficiently justified with adequate supporting information. This includes confirming that: Where sample documentation is required by the audit guidelines, adequate and appropriate supporting documentation are attached to the assessment to verify the responses Overall documentation must verify the employer s health and safety activities over the previous twelve month period Where notes are required by the audit guidelines, sufficient quality and quantity of assessor notes are provided to verify a yes response The information provided within a question and across all questions is not contradictory The audit instrument and process have been applied and followed as per the audit guidelines All no responses have been addressed by clear and relevant action items in the SECOR action plan form A SECOR assessment submitted with out-of-date or incomplete documentation that fails to establish an employer s health and safety activities over the previous twelve months will not pass the QA review and be rejected The audit score for a SECOR assessment completed by a company SECOR assessor will be calculated by the Enform audit QA reviewer Enform shall provide SECOR assessors the opportunity to address any audit deficiencies identified in the audit QA review process. There are two critical time deadlines associated with the audit correction process: SECOR assessors must return a corrected audit within 30 days of receiving their audit QA review feedback asking for clarifications or corrections The total timeline permitted for the audit QA review/audit correction process is 90 days from the auditors receiving their first audit QA review feedback Where deficiencies are not sufficiently addressed within this QA timeframe, the QA standards have not been met and the audit will be rejected Any deficiencies in the SECOR audit must be captured in the action plan form Deficiencies identified by the QA reviewer that were not originally noted by the SECOR assessor will be noted in the audit QA review feedback Employers are expected to revise their original action plans to account for any additional deficient items identified by the QA reviewer Employers with deficient action plans will not be required to submit a revised action plan to pass their audit QA review Employers may be asked to submit their previous year s action plan to demonstrate or confirm progress on action items SECOR Assessment Quality Assurance Review Approved: March 24, 2017 Page 2 of 4

110 Upon successful completion of the SECOR audit QA review process, Enform shall inform the employer in writing Enform shall not accept audit reports for certification or maintenance of certification purposes that fail to meet the quality standards applied in the audit QA review. Procedure The employer will be informed of a decision by Enform to reject an audit report that fails the Enform audit QA review process. The SECOR assessor: Completes the SECOR assessment according to Enform s audit standards. Submits their SECOR audit report to Enform within the required timeframes. Enform will: Ensure all SECOR training requirements for the employer and SECOR assessor are met. Complete a QA review on the audit report using the appropriate Enform SECOR assessment QA review form. o The notes and information provided with the audit must be sufficient to justify an 80%+ overall and 50%+ per element score for a certification audit and sufficient to demonstrate health and safety activities for the previous year for a maintenance audit. If required, request corrections, clarifications, or additional information If the audit report successfully passes the audit QA review process and receives approval, Enform shall: o Inform the employer in writing that the audit has passed audit QA review. o Inform the assessor of the approval and remind them of their responsibility to provide the employer with a final, approved version of the audit. o Processes the audit for certification or maintenance purposes o Notify applicable governing bodies, if applicable. In the event that the audit report requires corrections before it can be approved: The SECOR assessor has 30 days to address all issues identified by Enform in the SECOR Assessment Quality Assurance (QA) Review Form and resubmit the audit for a second audit QA review. If the corrections are adequately addressed, the audit report is processed as approved. If the corrections are insufficient, additional rounds of corrections may be required. The total time allowed for all correction cycles is 90 days from the date the assessor received the first round of audit QA review feedback. In the event of an audit report failing to meet the QA standard within the required timeframes: The audit is rejected as insufficient for certification or maintenance purposes. o The employer will be informed of this decision SECOR Assessment Quality Assurance Review Approved: March 24, 2017 Page 3 of 4

111 o A fresh assessment will need to be conducted if the employer wishes to achieve certification, recertification or maintenance of their COR. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.30 SECOR Assessment Quality Assurance Review Approved: March 24, 2017 Page 4 of 4

112 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 3.31 SECOR External Audit Quality Assurance Background SECOR audit reports conducted by an Enform external auditor must pass a quality assurance (QA) review by Enform before they can be approved for the purposes of SECOR certification or maintenance. The audit QA review ensures that the reports meet all applicable Enform and provincial SECOR audit standards. Policy Audit reports completed for the purpose of SECOR certification or maintenance must successfully pass an Enform audit quality assurance (QA) review before the audit report can be approved A standardized SECOR external audit QA review form shall be used to evaluate the quality of the audit report (see Appendix O3: SECOR External Audit Quality Assurance (QA) Review Forms) Where required, the SECOR audit QA review forms have been approved by the applicable governing bodies Upon receipt of a SECOR audit, Enform staff shall ensure the employer has met the Enform SECOR training requirements Enform staff ensures at the time of audit registration that external auditors are qualified An Enform audit reviewer shall use the appropriate SECOR audit QA review form to ensure: Critical data concerning the employer, the external auditor, and audit have been included in the audit report. This includes: Employer name, address, contact name, phone number, fax number, and . External auditor name, phone number, and auditor certification number. WCB account number(s) and industry code(s) covered by the audit. Audit start date and last date on site. Employer profile and number of employees. External auditor sign-off SECOR External Audit Quality Assurance Review March 27, 2013 Page 1 of 4

113 When performing an audit QA review on a SECOR audit completed by an external auditor, the audit reviewer shall ensure all auditor notes sufficiently justify the auditor s yes or no responses to the audit questions. This includes confirming that: The notes reflect the correct validation method for the question (documentation, interview, or observation) The individual notes address all the documentation and informational requirements stipulated by the audit guidelines for the individual questions The audit instrument and process have been applied and followed as per the audit guidelines All no responses have been addressed by clear and relevant action items in the SECOR action plan form The audit score provided by the external SECOR auditor has been correctly calculated The auditor notes provided by the external SECOR auditor as scored by the QA reviewer meet a minimum overall standard of 80% Enform shall provide external auditors the opportunity to address any audit deficiencies identified in the audit QA review process. There are two critical time deadlines associated with the audit correction process: External auditors must return a corrected audit within 30 days of receiving their audit QA review feedback asking for clarifications or corrections The total timeline permitted for the audit QA review/audit correction process is 90 days from the auditors receiving their first audit QA review feedback Where deficiencies are not sufficiently addressed within this QA timeframe, the QA standards have not been met and the audit will be rejected Any deficiencies in the SECOR audit must be captured in the action plan form Deficiencies identified by the QA reviewer that were not originally noted by the external auditor will be noted in the audit QA review feedback Employers are expected to revise their original action plans to account for any additional deficient items identified by the QA reviewer Employers with deficient action plans will not be required to submit a revised action plan to pass their audit QA review Employers may be asked to submit their previous year s action plan to demonstrate or confirm progress on action items Upon successful completion of the SECOR audit QA review process, Enform shall: Inform the employer that they are to expect a final, approved version of the audit report from their auditor Inform the auditor they are responsible to provide the employer with a final, approved version of the audit SECOR External Audit Quality Assurance Review March 27, 2013 Page 2 of 4

114 Enform shall not accept audit reports for certification or maintenance of certification purposes that fail to meet the quality standards applied in the audit QA review The employer and the external auditor will be informed of a decision by Enform to reject an audit report that fails the Enform audit QA review process. Procedure The external auditor will: Complete the SECOR audit according to Enform s audit standards. Submit their SECOR audit report to Enform within the required timeframes. Enform will: Ensure all SECOR training requirements for the employer are met. Complete a QA review on the audit report using the appropriate Enform SECOR external audit quality assurance (QA) review form. o The QA review score assigned must be at least 80%. If required, request corrections, clarifications, or additional information If the audit report successfully passes the audit QA review process and receives approval, Enform shall: o o o o Inform the employer in writing that the audit has passed audit QA review and that they should expect a final, approved version of the audit from the external auditor. Inform the auditor of the approval and remind them of their responsibility to provide the employer with a final, approved version of the audit. Processes the audit for certification or maintenance purposes Notify applicable governing bodies, if applicable. In the event that the audit report requires corrections before it can be approved: The external auditor has 30 days to address all issues identified by Enform in the SECOR External Audit Quality Assurance (QA) Review Form and resubmit the audit for a second audit QA review. If the corrections are adequately addressed, the audit report is processed as approved. If the corrections are insufficient, additional rounds of corrections may be required. The total time allowed for all correction cycles is 90 days from the date the auditor received the first round of audit QA review feedback SECOR External Audit Quality Assurance Review March 27, 2013 Page 3 of 4

115 In the event of an audit report failing to meet the QA standard within the required timeframes: The audit is rejected as insufficient for certification or maintenance purposes. o o The employer and the auditor will be informed of this decision. A fresh audit will need to be conducted if the employer wishes to achieve certification, recertification or maintenance of their COR. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 3.31 SECOR External Audit Quality Assurance Review March 27, 2013 Page 4 of 4

116 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 4.1 Overview: Auditor Qualifications This section of the manual outlines policies and procedures for the process of auditor certification, recertification, performance management and Enform staff in the role of auditor. Eligibility requirements to participate are outlined as well as registration requirements for the auditor. Questions about specific policies or procedures should be directed to or option Overview: Auditor Qualifications Approved: April 12, 2013 Page 1 of 1

117 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 4.2 Auditor Certification Background Effective May 9, 2006, all Enform external auditors will need to meet the following requirements: A minimum of five years experience in the past 10 years practicing health and safety in a full time position. Must have at least one of the following: o o o Hold a certificate, diploma, or degree in Occupational Health and Safety and/or a Canadian Registered Safety Professional (CRSP) or other equivalent safety designation, Must be recognized as a Health & Safety Management System Auditor (CHSMSA) designation with at least a two-year diploma/degree from an accredited college/university, Hold a valid CHSMSA designation and demonstrate practicing health and safety for seven of the past 10 years. This standard does not apply to internal (maintenance) auditors. Educational Requirements There are two safety designations that will considered to have meet the minimum educational requirements to become an Enform external auditor: Canadian Registered Safety Professional (CRSP) Certified Safety Professional (CSP) Health & Safety Management System Auditor (CHSMSA) designation with at least a two-year diploma/degree from an accredited college/university and experience in five of the past 10 years practicing health and safety in a full time position. CHSMSA designation and demonstrate practicing health and safety for seven of the past 10 years. The Board of Canadian Registered Safety Professionals (BCRSP) only recognizes one other designation as equivalent to the CRSP and that is the Certified Safety Professional (CSP) designation out of the United States. Other designations such as Construction Safety Officer (CSO), International Organization for Standardization (ISO) and Canadian Health and Safety Consultant (CHSC) have not 4.2 Auditor Certification Approved: January 1, 2017 Page 1 of 4

118 been granted equivalency and will not be considered to have met the minimum educational requirements to become an Enform external auditor Eligible certificate, diploma or degree Occupational Health and Safety programs must meet the following minimum requirements: Be issued from an accredited institution Consist of a minimum of 300 hours of classroom instruction and/or self-study Cover the following ten applications-based core competencies: o Accident Theory o Incident Investigation o Safety Techniques/Technology o Occupational (Industrial) Hygiene o Emergency Preparedness and Response o Risk Management o Ergonomics o OHS Law and Ethics o OHS Legislation/Regulation o Safety Management Systems The ten application-based core competencies are based on the guidelines from the Board of Canadian Registered Safety Professionals (BCRSP) and Enform s IRP Volume #9: Basic Safety Program. In order to assess program, the external auditor applicant must provide the following information for analysis: Proof of Program Completion - Copy of Certificate, Diploma or Degree Complete list of Program Transcripts List of Program Courses which includes: o Course description o Number of hours credited International programs will be considered however, the external auditor candidate must provide the following information: Description of Course Work Assessment completed by the International Qualifications Assessment Service (IQAS) o o The cost of the IQAS assessment is the responsibility of the external auditor applicant 4.2 Auditor Certification Approved: January 1, 2017 Page 2 of 4

119 Work Experience Requirements The minimum work experience requirements for external auditors are five years as a health and safety professional in the last ten years. Each job position will be evaluated and in order to be considered as a health and safety professional position, the following requirements must be met: The position must be full time. The health and safety function of the position must be greater than 50%. The position must be at a professional level. o o Must be engaged in the OHS occupation for pay and livelihood Collateral duties in OHS are not considered a primary function (i.e., Small business owner completing a SECOR self-assessment) The position s responsibility must be the prevention of harm rather than responding to harmful events. The position must have a broad scope of OHS responsibilities that includes at least 60% of the following: OHS Duties Incident Investigations & Analysis Hazard Identification Hazard Assessment Hazard Control Conducting Inspections (Work site, Equipment, etc) Developing and Review of Policies & Procedures Developing & Delivering H&S Training Delivering H&S Orientations Participation in H&S Committee and/or Safety Meetings Develop & Review Emergency Response Procedures Auditing of H&S Management Systems Communicate Safety Initiatives Interpretation of OHS Legislation Returning Auditors Auditors who are reapplying into Enform s Certified Health and Safety Program that were certified in the past would not be eligible to reapply if any of the following conditions exist: Received in the past an infraction through the Enform Auditor Performance Management System resulting in permanent suspension Received in the past an infraction resulting in a Serious Ethical Infraction under the Enform Auditor Performance Management system. It has been 2 years or more since the end of the suspension period from the last Serious Ethical Infraction discipline letter. 4.2 Auditor Certification Approved: January 1, 2017 Page 3 of 4

120 Application Process The applicant will: Complete Enform's two-day Safety Program Development Course. o This two-day course must be completed before you can register for the 5-day Certified Health and Safety Auditor Program course. Complete and submit the External Auditor Application form for review two months prior to the desired course date (application including downloadable Professional Reference Forms are available at Register for the Certified Health and Safety Auditors Program (CHSAP) within four months of the approval date. Complete Enform's 5-day CHSAP within one year of the approval date. You must achieve at least 80% on the final exam. Review and sign acceptance of Enform's Certified Auditor's Agreement. Submit a qualifications audit to Enform within six months of completing the CHSAP. Your quality assurance (QA) review score must achieve at least 80%. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 4.2 Auditor Certification Approved: January 1, 2017 Page 4 of 4

121 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 4.3 Auditor Recertification Background Health and Safety Auditor Certification is valid for a three-year period. Certified auditors must recertify at least once every three years. All auditors who completed the Certified Health and Safety Auditor Program prior to November 2008 will be required to successfully complete the revised Certified Health and Safety Auditor exam at auditor recertification stage. Policy Certified auditors must be recertified at least once every three years To be eligible for recertification, auditors must: Attend the one-day Certified Health and Safety Auditor Renewal course. Successfully complete a minimum of two audits or maintenance audit options within the three year auditor certification period If the auditor s certification has expired, the auditor will have up to six months from the date of expiry to recertify without having to retake the five-day Certified Health and Safety Auditor Program. Auditors whose certification has expired will not be permitted to register any new audits until they have completed the one-day Certified Auditor Renewal course Auditors whose certification has been expired for six months or more are required to reapply to retake the five-day Certified Health and Safety Auditor Program and complete a qualification audit. External auditor candidates must meet the current external auditor pre-requisites in order to complete the Certified Health and Safety Auditor Program Auditors who completed the Certified Health and Safety Auditor Program prior to November 2008 will be required to write and pass Enform s revised auditor training exam as a recertification requirement. The required passing mark on the Certified Health and Safety Auditor exam is 80%. Once an auditor has successfully passed Enform s revised exam, there is no requirement to rewrite the exam again in subsequent recertification years. 4.3 Auditor Recertification Revised: June 19, 2013 Page 1 of 2

122 An existing auditor who scores less that 80% on the Certified Health and Safety Auditor exam will be allowed one exam re-write within three months of taking the original exam. An existing auditor who scores less than 80% on the Certified Health and Safety Auditor exam will not be permitted to register any new audits until they have successfully passed the exam, regardless if the auditor s certification has expired or not. Auditors will be required to retake the five-day Certified Health and Safety Auditor Program in the following situations: o o o The auditor scores less that 80% on the re-write of the Certified Health and Safety Auditor exam. The auditor fails to re-write the Certified Health and Safety Auditor exam within three months of taking the original exam. The auditor fails to re-write the Certified Health and Safety Auditor exam within six months of the auditor s certification lapsing. Existing auditors who choose to retake the five-day Certified Health and Safety Auditor Program will have to submit a new auditor application (internal or external) and meet all of the same requirements as new auditor candidates. Procedure The auditor will: Recertify at least once every three years by completing the following requirements: o o o Attend the one-day Certified Health and Safety Auditor Renewal course. If applicable, achieve a mark of 80% or higher on the revised auditor training exam. Successfully completing a minimum of two audits or maintenance audit options within the three year auditor certification period. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 4.3 Auditor Recertification Revised: June 19, 2013 Page 2 of 2

123 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 4.4 Auditor Performance Management Background As a Certifying Partner, Enform is obliged to ensure its certified auditors maintain a high standard in terms of ethical behavior and professional performance in their auditing role. Furthermore, Enform has an obligation to its industry partners. Our industry partners should carry a positive expectation that auditors certified by Enform will consistently conduct themselves with honesty and the highest degree of professionalism. The following policy is meant to create accountability to this high standard. Specifically, it outlines how Enform manages auditors when their performance raises either ethical and/or audit quality assurance ("QA") issues. Auditor performance concerns and issues may come to Enform's attention through a number of avenues: Observations and investigations carried out as part of Enform's Audit QA Review. Discoveries made as a result of an onsite visit to a COR client during or after an audit is conducted. Complaints or reports from COR clients. Complaints or reports from other Enform Certified COR Auditors. The results of an On Site Audit Review. A Visual Guide to the Enform Auditor Performance Management Policy and Procedure is available in the Appendix. Policy Applicable to All Auditors and Auditor Issues In this Auditor Performance Management Policy, "Auditor" means an Enform-certified Auditor In this Auditor Performance Management Policy, "Management Representative" means a representative from the department responsible for overseeing Enform's COR program In this Auditor Performance Management Policy, "Policy" means the Auditor Performance Management Policy An Auditor will be provided access to the Policy as part of the auditor certification process As a condition of maintaining an Enform auditor certification, the Auditor shall agree to be bound by the disciplinary process outlined in the Policy by signing the Enform Certified Auditor's Agreement (hereafter referred to as "Agreement") (see Appendix). 4.4 Auditor Performance Management Approved: December 12, 2012

124 4.4.6 Reported and/or confirmed Auditor performance issues, whether relating to ethical or QA issues, will be documented on the Auditor's file as follows: If Enform concludes, on the basis of its investigation, that a suspected Auditor performance issue was not established, the documentation on the Auditor's file will reflect that the matter was investigated and found to be unsupported. This documentation will remain on the Auditor's file for a period of 2 years, after which it will be removed The Auditor in question may or may not be notified by Enform, in Enform's sole discretion, that such documentation has been placed on the Auditor's file If Enform's investigation concludes that the Auditor performance issue is proven, the results of the investigation and the associated disciplinary measures will be permanently recorded on the Auditor's file Any organization that is affected by an Auditor performance management issue, whether relating to ethical or QA issues, may be notified by Enform, as set out in the Agreement If Enform receives notice from another Certificate of Recognition Certifying Partner that an Auditor has committed one or more infractions of that Certifying Partner's policies or code of ethics, Enform may initiate its own investigation of the Auditor. As part of its investigation, Enform may discipline the Auditor in accordance with this Policy, but is not obligated to do so Once Enform begins an investigation into an Auditor's performance, and particularly when disciplinary measures affecting the Auditor's certification are a possible outcome, Enform may place the Auditor under an Interim Suspension while Enform's investigation takes place ("Interim Suspension"). In that case, Enform will notify the Auditor in writing of the Interim Suspension An Auditor subject to an Interim Suspension is prohibited from registering any new audits with Enform Upon being notified of an Interim Suspension, Enform will communicate what, if any, audits the Auditor may complete during the Interim Suspension Any audits completed and submitted after an Interim Suspension is imposed and for which written approval was not obtained may not be accepted by Enform An Interim Suspension is imposed at Enform's discretion when there is reason to believe that harm could result if the Auditor is not suspended during the remainder of the investigation An Interim Suspension will be in effect from the time it is imposed for a maximum of 90 days, or until Enform issues a disciplinary decision, whichever is earlier In all cases, Enform will use best efforts to limit the duration of the Interim Suspension The duration of any Interim Suspension will form part of and be credited toward the term of any subsequent suspension imposed by Enform as part of the disciplinary measures imposed on the Auditor in accordance with this Policy. 4.4 Auditor Performance Management Approved December 12, 2012 Page 2 of 13

125 If the Auditor has committed more than one infraction, whether ethical or QA in nature, Enform shall determine whether the disciplinary measure for each infraction will be served one after another, or concurrently During the course of its investigation into an Auditor performance issue, Enform may request information from the Auditor, including, but not limited to documents, software, s, copies of the Auditor's contracts with Employers, draft and final versions of audit reports and field notes, correspondence between the Auditor and Employers, notes from meetings between the Auditor and Employers, recordings, and any other information that may reasonably be expected to assist Enform in its investigation During the course of its investigation, Enform may request that the Auditor answer questions or provide additional information regarding the issues under investigation The Auditor shall provide the information set out in sections and within a reasonable timeframe, as set by Enform The Auditor's refusal or omission to provide the information Enform requests may, in Enform's discretion, result in an adverse inference being drawn against the Auditor During Enform's investigation, or at its conclusion, the Auditor will be given an opportunity to respond to Enform's concerns Any disciplinary decision reached by Enform will be communicated to the Auditor in writing Disciplinary decisions are effective immediately upon notice to the Auditor by Enform Enform's written notice to the Auditor setting out the disciplinary decision will be accompanied by instructions on the appeals process If the Auditor submits a request for an appeal, the commencement of the disciplinary decision made under the Policy is not delayed or suspended during the time when a request for an appeal could be made, during the time prior to the date of a scheduled appeal, or while an appeal is being heard All other applicable Certificate of Recognition Certifying Partners and government(s) will be notified if the Auditor is suspended for 12 months or more as a result of discipline in accordance with this Policy Enform may disclose to any one or more of the following entities any disciplinary decision that results in the Auditor's suspension and the findings upon which the disciplinary decision was based: Professional organizations, including self-governing and certifying bodies relevant to auditor certification; The Canadian Association of Oilwell Drilling Contractors ("CAODC"), in cases when the suspended Auditor is also an approved CAODC auditor; and Law enforcement and regulatory agencies. 4.4 Auditor Performance Management Approved December 12, 2012 Page 3 of 13

126 Ethical Issues The following section outlines Enform's policy and procedures with respect to any breach or allegation of a breach of the Enform Auditor Code of Ethics by the Auditor An initial investigation of a breach of the Enform Auditor Code of Ethics will be conducted, and, based on the results of the initial investigation, an in-depth investigation may then be carried out If the Auditor is disciplined by Enform for ethical reasons, information regarding the investigation and discipline will be shared with Enform's training department(s) Enform may rely upon information obtained during its investigations under the Policy when determining whether to accept the Auditor's application to provide training, or when investigating the Auditor's performance as an existing trainer with Enform's training department(s) Enform may obtain information about the Auditor from other Enform departments that may affect the Auditor's compliance with the Enform Auditor Code of Ethics, and Enform may rely upon that information in its investigation into the alleged breach of the Enform Auditor Code of Ethics If, as a result of investigation, Enform concludes that the Auditor has committed ethical infractions in relation to multiple audits, each audit so affected may be deemed to have been a single ethical infraction, and each of those single infractions may be deemed to have occurred sequentially, based on the date and time of each audit's registration. An example is boilerplating multiple audits When considering whether an infraction is "Minor", "Significant", "Serious", or a "repeated minor ethical infraction", Enform may refer to documented disciplinary measures on the Auditor's file that have occurred since July 1, The following table outlines more precisely how Enform classifies and investigates various ethical infractions and the penalties assigned to these types of infractions In this section, "repeated" means any infraction after the first infraction "repeated minor ethical infraction" means any infraction after the first infraction, regardless of whether the nature of the repeated infraction is the same as the first infraction or relates to a different violation of the Enform Auditor Code of Ethics. 4.4 Auditor Performance Management Approved December 12, 2012 Page 4 of 13

127 Classification Description Investigation/Decision Appropriate Penalties Note to File Unsubstantiated / Non-verifiable / False reports of breaches of the Enform Auditor Code of Ethics Investigation by Enform; Decision by Management Representative Note will be placed on the Auditor's file, including the outcome of investigation. Auditor may be informed of this action by letter. Minor Infraction Any infraction of the Enform Auditor Code of Ethics that is relatively minor in nature and does not impact on the approval of an audit Investigation by Enform; Decision by Management Representative May include any one or more of the following: Warning Letter Refresher Training Repeat Auditor Training and Qualification audit Suspension of up to 6 months Significant Infraction Includes a repeated minor ethical infraction. Also includes any ethical infraction that results in an audit's rejection by Enform, and/or an employer losing its COR status. Investigation by Enform; Decision by Management Representative Must include any one or more of the following on the Auditor's 1 st offence in this category: Repeat Auditor Training and Qualification Audit Suspension of up to 6 months Must include any one or more of the following on the Auditor's 2 nd offence in this category: Repeat Auditor Training and Qualification Audit Suspension of up to 1 year Serious Infraction These include third infractions, which may follow any combination of two earlier infractions, whether the first two infractions were "Minor", "Significant", or "Serious". Also includes any violation of the Enform Auditor Code of Ethics that calls into question the Auditor's honesty, integrity, diligence, or professionalism. Investigation by Enform; Decision by Management Representative Must include the following on the Auditor's 1 st offence in this category: Suspension of up to 6 months to 1 year, repeat Auditor Training and Qualification Audit Must include the following on the Auditor's 2 nd offence in this category: Suspension of 1 to 2 years, repeat Auditor Training and Qualification Audit May include the following on 1 st and 2 nd offences and must include the following on any 3 rd offence in this category: Permanent revocation of the Auditor's certification 4.4 Auditor Performance Management Approved December 12, 2012 Page 5 of 13

128 Audit Quality Issues The following section outlines Enform's policy and procedures with respect to any serious, unaddressed, or repeated shortcomings in audit quality by the auditor Enform will identify QA issues in the course of providing Audit QA Review to the Auditor Enform will inform a Management Representative about any concerns regarding repeated QA issues or an audit of such low quality that it cannot pass the Audit QA Review process Enform will consider whether the nature of the QA issue is a Minor QA Issue, in which case Enform will provide the Auditor with written notice to that effect and may take additional actions, as set out in the chart below If the nature of the QA issue is classified as a "First Significant Issue", Enform will communicate the same to the Auditor and may take additional actions, as set out in the chart below If the nature of the QA issue is classified as a "Second Significant Issue" or "Third Significant Issue", Enform will communicate the same to the Auditor and take appropriate action, as set out in the chart below If the investigation concludes that the Auditor has committed quality assurance infractions in relation to multiple audits, each audit so affected may be treated as a single infraction and may be deemed to have occurred sequentially, based on the date and time of each audit's registration When considering whether an infraction is a "Minor Quality Assurance", "First Significant", "Second Significant", "Third Significant" or a "repeated Minor QA" infraction, Enform may refer to documented disciplinary measures on the Auditor's file that have occurred since July 1, The following table outlines more precisely how Enform classifies and investigates audit QA shortcomings by the Auditor In this section, "repeated Minor QA Issues" means QA issues whose nature and frequency demonstrate that the Auditor is not making best efforts to institute Enform's requested changes and instructions in order to ensure the Auditor's compliance with Enform's policies and procedures regarding auditing, or the Health and Safety Certificate of Recognition Program: quality assurance standards. 4.4 Auditor Performance Management Approved December 12, 2012 Page 6 of 13

129 Classification Description Investigation/Decision Appropriate Penalties Minor Quality Assurance Issues Administrative and/or correctable audit deficiencies Addressed via ongoing Audit QA processes; Flagged and investigated by Enform; Decision by Management Representative Written feedback to the Auditor on the first review Communication with Auditor with a follow-up letter if deficiencies identified in the first review are not corrected in the Auditor's second submission of the audit. Any failure on the Auditor's third or fourth submission of the audit may result in the audit being rejected by Enform and, as such, the QA issue will then be considered a "Significant QA Issue". A warning letter must be sent before repeated issues are classified as "Significant". First Significant Issue Repeated Minor QA Issues or any QA issue(s) that result in an audit's rejection by Enform Investigation by Enform; Decision by Management Representative Must include telephone contact and a warning letter to the Auditor. May also include one or more of the following: Refresher Training; Repeat Auditor Training Qualification Audit. Second Significant Issue Failure to address any issue(s) already addressed as a First Significant Issue Investigation by Enform; Decision by Management Representative Must include any one or more of the following, in addition to telephone contact and a warning letter: Refresher Training; Repeat Auditor Training; Qualification Audit Suspension of up to 1 year Third Significant Issue Failure to address any issue(s) already addressed as a Second Significant Issue Investigation by Enform; Decision by Management Representative Must result in a permanent revocation of the Auditor's certification. 4.4 Auditor Performance Management Approved December 12, 2012 Page 7 of 13

130 Certification Reinstatement An Auditor who has been assessed any restriction(s) on his or her certification (as an Enform Certified Auditor) will need to meet all of the conditions set out in the Policy, as applicable, before being reinstated In advance of being considered for reinstatement: The Auditor must satisfy all of the conditions and requirements outlined in the discipline letter or appeal decision letter, as applicable, Any training requirements applied are only considered completed once confirmation of a successful completion is formally processed by Enform. As such, any exam or other course requirements would need to be completed, receive a passing grade from the instructor, and be processed by Enform before the training requirements would be considered met If a Qualification Audit is required as part of the Auditor's discipline, the audit must meet all of Enform's audit standards and pass the Enform QA Review. Conditions regarding the Qualification Audit will be removed when the audit passes the QA review and is processed as an approved audit by Enform An Auditor may neither register nor start any new audit during the suspension period. Auditors are only permitted to complete and submit audits specifically referenced in the discipline letter or appeal decision letter, as applicable. Qualification Audits are subject to the same restrictions as any other audits and may only be registered and started once the suspension period has ended An Auditor will be invited to meet with a Management Representative from Enform. This meeting will be offered by Enform at a time and location, and through a means of communication (telephone, videoconference, etc.), intended to be convenient for the Auditor. Refusal to attend this meeting will not prevent reinstatement once all disciplinary requirements have been met, but the Auditor's refusal to attend will be documented on the Auditor's file. The purpose of the meeting will be to: Clarify Enform's expectations of the Auditor's performance and possible consequences if these expectations are not met. Outline resources Enform has made available to the Auditor to assist the Auditor in meeting the expectations. To provide the Auditor with an opportunity to ask Enform questions regarding auditing and/or Enform's expectations of the Auditor. 4.4 Auditor Performance Management Approved December 12, 2012 Page 8 of 13

131 Once all of the conditions and requirements have been satisfied by the Auditor, Enform will reinstate the Auditor's certification by: Sending the Auditor a letter outlining the reinstatement of the Auditor's certification Permitting the Auditor to register and start audits as applicable to his or her auditor certification An Enform Certified External Auditor's name will be placed on any publically accessible list of auditors, maintained by Enform, at the next time that the list is scheduled to be updated by Enform. Appeals Any Auditor who has been assessed some form of disciplinary decision may appeal the disciplinary decision in accordance with this Policy by following the Enform Framework for Auditor Performance Management Appeals may be heard only with respect to the decision and disciplinary measures made by a Management Representative Individuals hearing arbitrations under this policy will not include any person(s) who were involved in reaching the particular decisions appealed from The Auditor shall not appeal the content of government standards as set out by any government bodies that have responsibility for the COR program in their jurisdiction, and the Auditor shall not appeal the contents of Enform policies, such as those found in the Approved Enform Audit Protocol, or as set out in other written Enform policies and procedures The Enform Framework for Auditor Performance Management offers two levels of appeal: Level One: Formal Meeting with a Management Representative Level Two: Arbitration. arbitration is available when the auditor chooses to appeal the decision made by a management representative following a formal meeting. 4.4 Auditor Performance Management Approved December 12, 2012 Page 9 of 13

132 Level One: Formal Meeting with a Management Representative Requests for Formal Meeting The Auditor may challenge a disciplinary decision made in accordance with the Policy by making a written request for a Formal Meeting with a Management Representative within 14 days of being informed of the disciplinary decision. The postmark on an envelope or other official indicator of date sent, or the time indicated on electronic mail, whichever is earlier, will be taken as the date the Auditor was informed of the decision A written request for a Formal Meeting with a Management Representative to challenge a disciplinary decision must include the Auditor's reasons to support his or her position. The Formal Meeting will be limited to discussion of those matters directly related to the decision being appealed The address to which the request for a Formal Meeting must be sent is as follows: ENFORM Attention: Manager, Safety Audits & Certifications th Street N.E. Calgary, Alberta T2E 8N4 Formal Meeting Enform will use its best efforts to schedule a Formal Meeting with the Auditor on a date that is within 30 days of Enform's receipt of the Auditor's written request for a Formal Meeting The Formal Meeting may be held in person, by telephone call, or by video conference, in Enform's discretion The Management Representative and any additional Enform staff whose attendance would, in Enform's view, be of assistance, will be present at the Formal Meeting. At the Formal Meeting, the Auditor will have the opportunity to present reasons to support the Auditor's position. No additional persons are permitted to be present during the Formal Meeting The Management Representative will communicate, in writing, Enform's decision and reasons to the Auditor within 14 days of the Formal Meeting The Management Representative may uphold, modify or set aside the original decision, in accordance with this Policy. The Management Representative may not order a stay of the disciplinary measures ordered in the original decision prior to issuing a final decision after the Formal Meeting The decision of the Management Representative following a Formal Meeting can be appealed to an arbitrator. 4.4 Auditor Performance Management Approved December 12, 2012 Page 10 of 13

133 Level Two: Arbitration To initiate arbitration, the Auditor must provide a formal, written request for arbitration. Requests for Arbitration Requests for arbitration must: Be submitted in writing within 14 days of being informed of a disciplinary decision by Enform in order to be eligible for the arbitration process Include: The reason for the request for arbitration; The desired remedy; Copies of any documentation that will be used to support the auditor's position at the arbitration; and The names and contact information for any witnesses that will be called by the auditor Be addressed to the General Manager, Audits. The address to which the request for arbitration must be sent is as follows: ENFORM Attention: General Manager, Audits th Street N.E. Calgary, Alberta T2E 8N All requests for arbitration will be verified by Enform to ensure they were sent within the 14 day limit on appeals The postmark on an envelope or other official indicator of date sent will be taken as the date the request for arbitration was made The day when the request for arbitration is received in Enform's office will be the start date for any timelines in which Enform is required to respond to the request for arbitration in accordance with this Policy Within seven days of receipt of a request for arbitration, Enform will provide written notification to the Auditor confirming receipt of the request for arbitration If a request for arbitration does not comply with the requirements set out in this policy, Enform will advise the Auditor within seven days of having received the request for arbitration. No arbitration will be scheduled if the request for arbitration does not comply with this Policy If the request for arbitration is received by Enform, Enform will forward to the Auditor within seven days of receiving the request for arbitration the roster of arbitrators maintained by Enform. The roster includes those arbitrators approved by Enform from a list of potential arbitrators provided by the Director of Alberta Partnerships. 4.4 Auditor Performance Management Approved December 12, 2012 Page 11 of 13

134 Appointment of an Arbitrator The Auditor and Enform (the "Parties") must appoint a single arbitrator by mutual agreement within seven days after the roster of arbitrators is forwarded to the Auditor. If the Parties fail to agree on the selection of an arbitrator, either party may apply to the Director of Alberta Partnerships to appoint an arbitrator. The selection of an arbitrator by the Director of Alberta Partnerships is final and may not be appealed. Arbitration Hearings Arbitration hearings under this Policy will follow the rules for arbitrations set out in the Alberta Arbitration Act, as amended from time to time, with the following specifications and/or exceptions: All arbitration hearings will be conducted by a single arbitrator; All arbitrations must take place at a location that is mutually agreeable to both the Auditor and Enform; If the Parties cannot agree on the location for an arbitration hearing, the arbitrator will determine the location for the arbitration hearing; The actual costs of the arbitration, including arbitrator's fees, hearing costs and administrative expenses, as approved by the arbitrator, must be shared equally between the Parties and must not be allocated by the arbitrator as part of his or her decision; The arbitrator must issue interim reports on his or her services to the Parties every 15 days during the arbitration process unless the parties otherwise agree; The Parties must each be responsible for their own costs related to the arbitration, including but not limited to any legal fees, travel time and expenses, lost income, and witness fees; For arbitrations concerning the Auditor's suspension and/or revocation of certification, the arbitrator's decision is limited to actions outlined in the Policy; No arbitration award made under the Policy may include any award for monetary damages; All arbitration hearings under the Policy must operate as follows: The conduct of the arbitration hearing will be informal; The rules of evidence will not apply unless the Parties mutually agree that the rules of evidence will be in force; Each of the Parties will be allowed to present relevant documentation, evidence, witnesses and arguments to support its position; The arbitrator may ask questions and all answers to those questions will be directed to the arbitrator; 4.4 Auditor Performance Management Approved December 12, 2012 Page 12 of 13

135 The Parties will present in the following order; Enform will present its evidence; The auditor will present his or her evidence; Enform will present its arguments and final comments; and The auditor will present his or her arguments and final comments The Parties are not allowed to cross examine each other unless the arbitrator specifically allows this, in which case the arbitrator will also determine the extent to which any cross examination may be used The Parties are not bound to confidentiality with respect to the arbitrator's final decision. This includes details of the Auditor's certification status and any penalties imposed, if applicable, The arbitrator may uphold, modify or set aside Enform's original decision, or the decision made after the Formal Meeting, in accordance with the Policy In appeals from disciplinary matters, the arbitrator may uphold, reduce, increase, add or substitute penalties, in accordance with the Policy Arbitrators may not order a stay of disciplinary measures ordered by Enform before issuing a final decision, after the arbitration hearing The arbitrator must conduct the hearing and issue a signed, written decision to the Parties, including reasons for the decision, no later than 90 days after Enform received the request for appeal by arbitration The decision of the arbitrator is final and binding and cannot be appealed. Approval Paula M.A. Campkin, MBA, CRSP General Manager, Industry Development & Audit 4.4 Auditor Performance Management Approved December 12, 2012 Page 13 of 13

136 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 4.6 On-Site Audit Review Background An On-Site Audit Review (OSAR) is conducted to validate the key findings of Enform certified auditors and ensure appropriate audit process was followed. OSARs are not a re-audit of the employer s health and safety management system, they are intended to validate auditor results and audit processes. OSARs are completed by either the provincial governing body or by a representative of Enform. Policy In order to verify the work of external auditors conducting certification, recertification and maintenance audits, OSARs will be conducted annually OSAR selection will be based on any of the following criteria: Where Enform initiates and administrates the OSAR process, a minimum of 10% of total number of Enform certified external auditors will be subject to an OSAR within a given calendar year Auditor selection for the OSAR sample shall be based on the following guidelines: Whenever possible, the sample will include a mixture of the following: o high and low volume auditors o new and experienced auditors o audits covering a variety of employer sizes o audits conducted during different times of the year o provincial jurisdiction o audits prior to a recertification of a COR An auditor may be selected for an OSAR as a part of an investigation arising from questions about the auditor s work or a complaint from an employer. An auditor who has recently been recertified following a suspension may be selected for an OSAR. At the request of Enform or the governing body when audit quality issues have been identified or are suspected. 4.6 On Site Audit Review March 14, 2017 Page 1 of 5

137 4.6.3 In Alberta, the OSAR process is initiated and administered by the governing body (Partnerships) and, in consultation with Enform, shall select the auditors to be sampled in a given year Outside of Alberta, the OSAR process is initiated and administered by Enform Whenever possible, OSARs should be conducted within 60 days, and no more than 120 days, after an employer s original audit date (last day on site) The OSAR will focus on the following key areas: Were interviews conducted on a representative sample of the employer s workforce? Were site observations performed at all sites identified in the audit report? Did the auditor complete all critical audit steps? Does a review of key documentation validate the original auditor s findings? Do observations (if applicable) validate the original auditor s findings? Employers whose audits are selected as a part of the OSAR sample are required to participate in the process Enform or the governing body will advise the audited employer (in writing) that their audit was selected for OSAR An employer may be required to work with Enform or the governing body to correct any systemic deficiencies identified with their health and safety management system (see subsection 4.6.8) If an employer s audit is sampled as the result of a concern over the validity of a specific auditor s work, Enform may choose to not approve the audit report until the OSAR has been completed Should extenuating circumstances prevent a sampled employer from participating in the process, they must provide Enform or the governing body with written justification for their exclusion within seven days of their notification If an employer fails to cooperate with the OSAR process their COR may be cancelled by the governing body Should the OSAR reveal systemic deficiencies in the employer s OHS management system that were not identified by the original auditor, the following actions will be taken: Enform or the governing body will provide the employer with a written report outlining systemic deficiencies within 21 days of completion of OSAR data gathering activities In Alberta, Partnerships will refer the employer to the Employer Review process (see Enform Policy 6.14 Employer Review). Partnerships will request Enform to assist the employer to correct the deficiencies. 4.6 On Site Audit Review March 14, 2017 Page 2 of 5

138 4.6.9 Where significant deficiencies are identified with the auditor s performance/processes, Enform may initiate disciplinary action with the auditor (see Enform Policy 4.4 Auditor Performance Management) Enform may also prohibit the auditor from conducting the next certification audit for the employer Enform must provide the governing body with details of any follow-up investigations/disciplinary actions undertaken with the auditor as a result of an OSAR within 120 days of receipt of the OSAR Report If the matter is still in progress at 120 days, an update is required and when concluded, a final report of the actions undertaken must be provided OSA reviewers must meet the following minimum criteria. OSA reviewers must: Be certified Enform auditors Sign and abide by the Enform Audit Reviewer Code of Ethics (4.6.1 On Site Audit Reviewer Code of Ethics and Appendix R2 On Site Audit Reviewer Code of Ethics declaration) in order to avoid any conflict of interest, and to ensure confidentiality of the process Complete training on the OSAR process In jurisdictions where Enform administrates the OSAR process, OSA reviewers may be comprised of: Qualified Enform staff, or Consultant external auditors on behalf of Enform OSARs are not intended to be a complete re-audit of the employer s health and safety system. They are intended only to validate auditor results and processes On-site reviews are designed to take no longer than one day on site, though reviewers undertaken on very large employers may take two days to complete On-site reviews will be completed using Enform s OSAR template (Appendix R AB OSAR Report Template or Appendix R BC OSAR Template) The OSAR template will include fifteen (15) specific audit questions selected from a pool of possible audit questions. Enform may work from either a set list of audit questions or select the specific audit questions on a case-by-case basis prior to each OSAR An OSA reviewer may provide feedback to the employer on their health and safety management system if requested to do so by the employer. This feedback should: Avoid criticism of staff or the employer s original auditor. Be offered with the caveat that the reviewer has not had the opportunity to engage in a full systems audit. 4.6 On Site Audit Review March 14, 2017 Page 3 of 5

139 Procedure In jurisdictions where a governing body administrates the OSAR process: The governing body: Makes a determination on the number of Enform auditors that will be subject to OSAR and in conjunction with Enform, selects the audits on which the OSAR will be applied. Contacts the employer once an audit has been chosen for OSAR. Provides the OSA reviewer with the information required to conduct the OSAR. o This includes a process to sign-off that there is no conflict of interest between the reviewer and auditor. Enform: Provides Enform with a copy of the OSAR for follow up purposes with the auditor and employer as required. Provides feedback to the governing body on the suitability of OSA reviewer candidates. Provides timely updates on audits received to facilitate the auditor/audit selection process. Provides the names of auditors with possible performance-related issues as part of the auditor selection process. Provides the OSA reviewer with the original audit report upon request. Provides the original auditor with the OSAR results. As required, initiates an investigation when auditor performance issues are identified. As required, works with employer to address deficiencies identified with their health and safety management systems. Shares relevant OSAR findings/follow-up with governing bodies. Employers: Provide assistance to the OSA reviewer to have all requested documentation available at the time of the OSAR. Cooperate with the OSAR process. Correct any deficiencies identified in a timely manner as a result of findings in the OSAR process. 4.6 On Site Audit Review March 14, 2017 Page 4 of 5

140 The OSA Reviewer: Confirms they are not in a conflict of interest in reviewing the selected auditor. Contacts the employer to set a date for the OSAR. Requests the original audit report from Enform prior to completing on site information gathering activities. Performs the on-site review using Enform s OSAR protocol. Provides the governing body with a completed OSAR report within 21 days of on-site information gathering activities. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 4.6 On Site Audit Review March 14, 2017 Page 5 of 5

141 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 4.7 Verification Audit Background A verification audit provides an independent review of key areas of an employer s health and safety management system to validate that COR certification is justified. A verification audit can be triggered by questions about the validity of COR-certified employer s health and safety management system, questions about the performance of a given auditor, or at the specific request of a governing body. Policy A verification audit may be requested on a specific employer s health and safety management system under the following circumstances: A governing body may request a verification audit based on recent health and safety violations or outstanding orders issued against the employer Enform may request a verification audit as a part of an investigation into an auditor who completed a recent audit for the employer Employer participation in a verification audit is mandatory Auditors completing verification audits must be seasoned health and safety professionals with adequate auditing experience. Verification audits can be conducted by either: Qualified Enform staff, or Qualified external consultants on behalf of Enform The scope of the verification audit will be determined by Enform and the provincial governing body, where appropriate In situations where only certain portions of the employee s health and safety management system are in questions, a limited scope audit would apply The verification audit will be completed using Enform s COR Health and Safety Audit Protocol In the case of a limited scope audit, only selected questions from Enform s COR Health and Safety Audit Protocol would apply. 4.7 Verification Audit Approved: March 21, 2012 Page 1 of 3

142 4.7.6 Where appropriate, an On-site Site Audit Review (OSAR) may be completed at the same time as the verification audit OSARs will be completed using the Enform On-Site Audit Review Protocol (Appendix R) Enform shall schedule the verification audit directly with the employer The verification auditor shall: Complete the verification audit as per the pre-determined scope and in accordance with Enform s auditing standards Provide immediate feedback to Enform regarding any serious deficiencies in the employer s health and safety management system Provide a verification audit report within 30 days of the last day on site If applicable, the verification auditor must not provide feedback to the employer on the quality of the original audit while conducting their verification audit As a health and safety professional, the auditor is permitted and obligated to advise an employer if they observe situations of imminent danger to any employees Cases of serious auditor performance issues raised by the verification audit will be dealt with in accordance with the Enform Auditor Performance Management Policy and Procedure In the event an issue is raised concerning the employer s health and safety management system or the validity of the employer s COR, Enform shall: Wherever possible, negotiate a corrective action plan that can address the deficiencies within three to six months Where the original audit is shown to be deliberately misleading or grossly incompetent, Enform and/or governing bodies may require a follow-up Certification Audit within three to six months for the employer to maintain their COR status Communicate all negotiations and decisions regarding employers and their COR status with governing bodies where required In situations where an entire new audit was completed and the employer is in a maintenance year of their COR cycle, Enform will lobby the provincial governing body to have the verification audit count towards maintaining the employer s COR for the year As required, Enform will provide an annual report of verification audits conducted to the appropriate governing bodies. 4.7 Verification Audit Approved: Month March 21, 2012 Page 2 of 3

143 Procedure The governing body: Identifies employers that require a verification audit based on recent health and safety violations or outstanding orders. Requests that Enform perform a verification audit on an identified employer. Sends the employer a letter stating the requirement for a verification audit. Enform: May also identifies employers that require a verification audit based on an open investigation into an auditor who completed a recent audit for the employer. In consultation with governing body (where applicable), determines scope of verification audit (full audit vs. limited scope, etc.). Determines if OSAR will be completed at the same time. Selects qualified verification auditor(s). Notifies the employer of the verification audit date. The verification auditor: Conducts the verification audit in accordance with Enform s auditing standards using Enform s COR Health and Safety Audit Protocol. If applicable, advises the employer if they observe situations of imminent danger to any employees. Completes an OSAR Audit Report, if requested to do so. Provides immediate feedback to Enform regarding serious deficiencies in the employer s health and safety management system. Provides a final verification audit report to Enform within 30 days of the last day on site. Following receipt of the verification audit report, Enform: Reviews verification audit findings. Where serious issues are identified with the employer s health and safety management system, works with the employer to set an action plan to deal with the deficiencies. As applicable, informs applicable governing bodies of outcome of individual verification audits and subsequent action plans. Where auditor performance issues are identified, deals with the matter in accordance with the Auditor Performance Management Policy. Forwards an annual summary report of verification audits to the governing bodies as required. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 4.7 Verification Audit Approved: Month March 21, 2012 Page 3 of 3

144 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 4.8 Enform Employees as Auditors Background COR staff members are encouraged to pursue Enform Auditor Certification for professional development purposes. A part of completing and maintaining auditor certification is conducting audits. However, it is important to distinguish those situations where Enform employees may conduct audits from those in which Enform employees conducting audits would be a real or perceived conflict of interest. Enform Employees Enform employees may conduct an audit for the purpose of completing or maintaining Enform Auditor Certification and/or for professional development, provided: There no charge for the audit. The audit is not used for an employer s COR certification. Quality assurance review of the audit cannot be completed by the person who performed the audit. Quality assurance review of the audit must be performed by a consultant reviewer when the audit is used for an employer s COR maintenance. The auditor remains bound by the Auditor Code of Ethics. Enform Contractors Enform contractors, including quality assurance reviewers and instructors are permitted to perform audits provided: Quality assurance review of the audit cannot be completed by the person who performed the audit. The auditor remains bound by the Auditor Code of Ethics. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 4.8 Enform Employees as Auditors Approved: March 11, 2013 Page 1 of 1

145 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 5.1 Standards for Audit Reviewers Background Audit reports must pass Enform s quality assurance (QA) review before the report can be approved. QA review is one of the most important ways in which Enform ensures consistent, high quality audit reports for employers in the COR program. To deliver audit reviews that are consistent and hold auditors to a high standard requires audit reviewers with sufficient education, training, and experience. This policy defines the basic standards of education and experience required of audit QA reviewers. Enform uses a combination of staff and consultant audit reviewers. Purpose This document defines the education, work experience and training standards required for an Enform Audit Reviewer. Enform Audit Reviewers are a key component to the quality and integrity of all competed audits/options submitted under Enform s audit protocols. Scope This standard applies to staff and contract audit reviewers. This standard covers the combination of work experience, education and credentials required to perform quality assurance reviews. This document outlines on the job training. Requirements There are three levels of Enform staff audit reviewers. The levels are established to determine the type of audit/audit options that can be reviewed. All audit reviewers in training will be assigned a mentor during their training. All audit reviewers will have the minimum education: Hold a certificate, diploma or degree in health and safety or have completed at least 50% of their health and safety education, or hold a diploma, degree in nonrelated course. 1. Pre-requisite courses for audit reviewers: Petroleum Safety Training (PST) Enform Safety Program Development COR Program Orientation (inhouse) 5.1 Standards for Audit Reviewers Revised: June 2015 Page 1 of 3

146 Use the training checklist found in Appendix U1: SA&C Audit Reviewer COR Orientation Training Checklist 2. Level A audit reviewer requirements: One years of experience in occupational health and safety. Approved for Level A audit reviewer training. Use the training checklist found in Appendix U2: Level B Training Checklist 3. Level B audit reviewer requirements: Completed Level A audit reviewer training. Completed and pass Enform s Certified Health and Safety Auditor course. Approved for Level B audit reviewer training. Use the training checklist found in Appendix U3: Level B Training Checklist 4. Level C audit reviewer requirements: Completed Level B audit reviewer training. Two years of experience in occupational health and safety. Certified Enform Internal Auditor. Approved for Level C audit reviewer training. Use the training checklist found in Appendix U4: Level C Training Checklist 5. Contracted consultant requirements: Minimum of five years of experience with a broad spectrum in occupational health and safety. Hold a certificate, diploma or degree in health and safety or hold a Canadian Registered Safety Professional (CRSP) or equivalent. Be an Enform Certified External Health and Safety Auditor. Have no enforced quality and/or ethical infractions under Enform s Auditor Performance Management standards. Must complete level competency training for the audit protocol and types assigned for review. 6. All audit reviewers must sign and adhere to the Audit Reviewer Code of Ethics. An audit reviewer with any real or perceived conflict of interest with an Enform audit must contact the Enform managing supervisor to discuss. 5.1 Standards for Audit Reviewers Revised: June 2015 Page 2 of 3

147 7. All audit reviewers will have their worked regularly reviewed and will be provided with feedback. This will be carried out by the audit reviewer s managing supervisor/(s). o Use the form found in Appendix U5 and U6: Audit Re-Review QA Checklist for COR or SECOR AUDIT REVIEWER MATRIX Protocol/Type Maintenance Certification SECOR Assessor B B SECOR Assessor Re-sub n/a A SECOR External B B SECOR External Re-sub A A COR B C PASE n/a C Baseline C n/a Limited Scope n/a C Student Audit C n/a Action Plan B n/a Safety Surveys B n/a Type Participant Lead OSAR B C Procedure Enform will: Apply the above standard when selecting staff and consultant audit reviewers. Provide initial and ongoing audit QA review training. At least annually, review the performance of staff and consultant audit reviewers. Maintain a list of audit reviewers and make available to Enform certified auditors. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 5.1 Standards for Audit Reviewers Revised: June 2015 Page 3 of 3

148 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 5.2 Performance Management of Audit Reviewers Background Given audit reviewers serve a critical role in upholding COR standards in the audit process, tracking and improving their performance is critical to the integrity of the COR program as a whole. As a certifying partner, it is important that Enform takes reasonable steps to ensure the integrity and consistency of the work of both staff and contract audit reviewers. Policy Both staff and contract audit reviewers are subject to ongoing performance reviews at least annually Staff audit reviewers: Monitor the performance of contract audit reviewers by performing all the second reviews and resubmissions on audits originally reviewed by contract audit reviewers. Use the form found in Appendix U5 and U6: Audit Re-Review QA Checklist for COR or SECOR The supervising manager(s) of staff audit reviewers: Monitor(s) the performance of staff audit reviewers by performing second reviews and resubmissions on audits originally reviewed by staff audit reviewers. Use the form found in Appendix U5 and U6: Audit Re-Review QA Checklist for COR or SECOR All audit reviewers are expected to follow the Enform standard for audit QA review and remain fully compliant with the Enform Audit Reviewers Code of Ethics Minor deficiencies in audit QA review performance will be addressed though coaching and additional reviews to gauge improvement Serious breaches in upholding the Enform standard for audit QA review or the Enform Audit Reviewer Code of Ethics will be dealt with by the department manager. Disciplinary measures may extend to termination of employment or contract. Staff audit reviewers are subject to the Enform employee performance management process. 5.2 Performance Management of Audit Reviewers Approved: June 1, 2015 Page 1 of 2

149 5.2.5 If contract audit reviewers are subject to disciplinary measures as either Enform certified auditors or Enform certified instructors, this can and may be grounds for termination of their contract as Enform audit reviewers If contract audit reviewers are subject to disciplinary measures as audit reviewers, this can and may impact their status as Enform certified auditors or Enform certified instructors. Procedure Performance Management of contract audit reviewers Staff audit reviewers shall review any subsequent reviews and resubmissions from audits originally reviewed by contract audit reviewers. In the event minor deficiencies are identified in the work of contract audit reviewers, the staff audit reviewer will: o Provide coaching on the deficiency. o Review a sample of the contract audit reviewer s next review to gauge improvement. Performance Management of staff audit reviewers Second reviews and resubmissions from audits originally reviewed by staff audit reviewers will be periodically forwarded to the supervising manager(s) of staff audit reviewers. In the event minor deficiencies are identified in the work of staff audit reviewers, supervising managers will: o Provide coaching on the deficiency. o Review a sample of the staff audit reviewer s next review to gauge improvement. Supervising manager(s) of contract and staff audit reviewers In the event a serious breach of the Enform Audit Reviewer Code of Ethics or serious failure to correctly follow the Enform standard for audit QA review comes to the attention of the supervising manager(s) of audit reviewers, the manager(s) will: o Fully investigate the matter. o Address as appropriate, up to and including termination of employment or contract. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 5.2 Performance Management of Audit Reviewers Approved: June 1, 2015 Page 2 of 2

150 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 5.3 Code of Ethics for Audit Reviewers Background Audit reviewers, like auditors, are held accountable by a code of ethics. As with the Enform Auditor Code of Ethics, the goal is to prevent situations in which there is a real or perceived conflict of interest and to uphold professional standards. Policy Both staff and contract audit reviewers are bound by the Enform Audit Reviewer Code of Ethics (see Appendix T: Enform Audit Reviewer Code of Ethics) Both staff and contract audit reviewers are required to sign an agreement stating they will adhere to the Enform Audit Reviewer Code of Ethics (see Appendix U: Enform Audit Reviewer Code of Ethics Declaration). Procedure Staff Audit Reviewers: Sign the Enform Audit Reviewer Code of Ethics Declaration when hired or moved into an audit reviewer role. Contract Audit Reviewers: Sign the Enform Audit Reviewer Code of Ethics Declaration: o When first contracted to serve in an audit reviewer role. o Whenever subsequent contracts are signed for audit reviewer services. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 5.3 Code of Ethics for Audit Reviewers Approved: March 15, 2012 Page 1 of 1

151 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 5.4 Code of Ethics for Enform Safety Audits and Certifications Staff Background All Enform staff, including staff members of the Safety Audits & Certifications (SA&C) department, are subject to Enform s human resources policies that cover off internal matters such as respectful workplace, code of business conduct, conflict of interest, and privacy. However, since Enform SA&C staff regularly handle third party corporate information in the form of employer audit reports, additional directives are required for all SA&C staff members handling or processing these reports. SA&C staff members that are also audit reviewers are subject to both this code as well as the Code of Ethics for Enform Audit Reviewers. Policy All Enform Safety Audits and Certifications Staff members are bound by the Enform Safety Audits and Certifications Code of Ethics (see Appendix V: Enform Safety Audits and Certifications Code of Ethics) All Enform Safety Audits and Certifications Staff members are required to sign an agreement stating they will adhere to the Enform Safety Audits and Certifications Code of Ethics (see Appendix W: Enform Safety Audits and Certifications Staff Code of Ethics Declaration). Procedure SA&C staff members: Sign the Enform Safety Audits and Certifications Staff Code of Ethics Declaration when hired or move into the SA&C department. Enform: Maintains a record of completion of the Enform Safety Audits and Certifications Staff Code of Ethics Declaration by staff members. SA&C managers and supervisors: Manage the performance of Enform SA&C staff, investigate any possible breaches of the Enform Safety Audits and Certifications Staff Code of Ethics, and may impose disciplinary measures up to and including suspension or termination of employment or contract for serious breaches of the Code of Ethics. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 5.4 Code of Ethics for Enform SA&C Staff Approved: March 15, 2011 Page 1 of 1

152 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 6.1 Overview: Certification (Process and Types) This section of the manual outlines policies and procedures for the process for applying for different types of Certificates of Recognition (COR) such as three-year, one-year, six-month and MECOR. Eligibility requirements for these types are outlined as well as. Questions about specific policies or procedures should be directed to or option Overview: Certification (Process and Types) Approved: April 12, 2013 Page 1 of 1

153 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 6.2 Three-Year COR/SECOR Background A COR or SECOR will be issued to an employer whose health and safety management systems meets Enform s audit requirements. In Alberta and British Columbia, the COR/SECOR is issued by the provincial governing body and co-signed by Enform. An Alberta CORs/SECORs may also be co-signed by a sponsoring partner such as CAPP, PSAC, CAODC, EPAC, CEPA and CAGC. In all areas outside Alberta and British Columbia, the COR/SECOR is issued solely by Enform. Typical CORs/SECORs are issues for a three-year period from the certification audit date (last day of onsite audit activity) and remain valid provided the annual maintenance requirements are met. In some situations, a COR/SECOR may be issued for either six months or one year. This policy deals with issuing a standard three-year COR/SECOR. Policy Unless there is a stipulation that a certification audit is for a six-month COR or one-year COR/SECOR, employers will be awarded a three-year COR or SECOR upon successful completion of a certification audit The last day of onsite audit activities serves as the certification date. The COR/SECOR expiry date will be three years from this date Certification audits used to issue a three-year COR or SECOR must meet all the standards set out for COR certification audits, SECOR assessments, or SECOR external audits (see 3.3 Certification Audit; 3.6 SECOR Assessment Conducted by a SECOR Assessor; and 3.7 SECOR Audit Conducted by an External Audit). These policies outline critical standards for certification including: The employer has documented evidence of having had a health and safety management system in place for at least one year The employer has active work sites available at the time of the audit. 6.2 Three Year COR/SECOR Approved: June 12, 2013 Page 1 of 5

154 The audit is carried out by an Enform external auditor for employers in the COR program or employers in the SECOR program opting for a SECOR external audit. In the case of a team audit, this stipulation applies to the lead auditor (see 3.20 Team Audit). Certification audits may also be carried out by approved corporate auditors (see 3.28 Use of Corporate Auditors) The SECOR assessment is carried out by a qualified SECOR assessor if it is a SECOR assessment for certification (see 3.6 SECOR Assessment Conducted by a SECOR Assessor and 3.8 SECOR Assessor Code of Ethics) The audit is performed on an approved audit protocol and meets all the established timelines and quality standards The audit must be conducted during typically high/medium times of activity for the year. Workplace activities must be representative of the employer s operations For employers who experience fluctuating activity levels due to changes in general economic conditions, Enform will assist in determining the sampling requirements based on the employer s best estimate if their high/medium times of activity for the current year, provided that the employer has at least one active work site Employers who acquire new operations may require a new external audit to certify the expanded scope of their business The audit achieves a score of 80% or higher overall and not less than 50% on each audit element The audit passes the Enform audit QA review process (see 3.29 COR Audit Quality Assurance Review, 3.30 SECOR Assessment Quality Assurance Review, and 3.31 SECOR External Audit Quality Assurance) The three-year COR/SECOR certificate will be issued based on the employer s WCB account number(s) and industry code(s)/classification unit(s) covered in the scope of the certification audit under the legal name registered with the WCB In the case that a certification audit covers multiple provincial jurisdictions or multiple WCB accounts, a separate certificates will be issued for each provincial jurisdiction and/or each WCB account Enform will maintain the associated WCB account number(s), industry code(s)/classification unit(s), legal names and trade names, and where applicable site names (for site specific audits in Alberta only), in its database record of the certification. These are forwarded to governing bodies as required. These elements will be printed on the official certificate itself as per each provincial jurisdiction s practice. Where Enform issues the official certificate, the trade name, industry code(s)/classification unit(s), and where applicable, the site name will be included on the certificate. 6.2 Three Year COR/SECOR Approved: June 12, 2013 Page 2 of 5

155 6.2.4 For an employer to maintain their COR/SECOR certification over the full three years, a maintenance audit or approved maintenance option must be carried out in the second and third calendar year of certification Maintenance audits or approved options must cover the full scope of the original certification and meet all the required timelines and standards applicable to the audit or option, including successfully passing Enform s audit QA review. With the exception of employers in the MECOR process where there is an audit score requirement for maintenance audits, there are no minimum score requirements for a maintenance audit. However, the audit must pass the Enform audit QA standard Where an employer receives multiple certificates for a given certification audit, these certifications may be maintained independently or collectively with subsequent maintenance audits. Maintenance audits must cover the entire scope of a given certification in order to meet maintenance requirements on a given certification Enform will track maintenance requirements on a per certificate basis and provide initial notice and timely reminders to employers on their maintenance requirements. Enform will notify all employers that have failed to maintain their certification that their COR/SECOR has been revoked A SECOR certification is only available to an employer that has ten or fewer employees across their entire scope of operations An employer may not apply for SECOR certification for a specific site or industry if their overall operations exceed 10 employees An employer is not permitted to have a COR certificate and a SECOR certificate simultaneously Where applicable, Enform will apply to the appropriate governing body to have a COR or SECOR issued to employers who succeed with their certification audit Governing bodies retain the right to: Review all applications for a COR/SECOR. Ask for clarification on any issue from Enform before issuing a certificate Governing bodies may check for any occupational health and safety regulatory activity that has occurred within the previous twelve months to the COR/SECOR request. If the governing body has significant concerns with the employer s health and safety management system and/or if officer orders have been written, the COR/SECOR request may be denied. Matters of significance may include: An employer refusing to comply with an order. Stop work orders for imminent danger. Repeat orders for the same violation. Outstanding orders. Matters concerning the employer s hazard assessments, required training, or emergency response. 6.2 Three Year COR/SECOR Approved: June 12, 2013 Page 3 of 5

156 6.2.8 Enform will forward all employer certificates received from governing bodies to employers If the COR/SECOR requires the signature of a sponsoring partner (CAPP, PSAC, CAODC, EPAC, CEPA and CAGC), Enform will make the arrangements to obtain this additional signature In those cases where Enform issues COR/SECOR certificates directly, these will be issued following the successful completion of the Enform audit QA review process All companies achieving and maintaining a three-year COR/SECOR certification will be listed on the Enform website The information included will be the employer s legal and trade name, COR type, and certification expiry date Employers may opt out of this service by providing Enform with a written request to have their names removed from the list. Procedure The employer: For COR certification, contracts the services of an Enform external auditor. For SECOR certification, either contracts the services of an Enform external auditor or fulfills the requirements to serve as a SECOR assessor. The external auditor or SECOR assessor will: Provide the employer and audit scope information both at the time of audit registration and upon report submission to ensure all required information for certification purposes is accurately captured. Perform a certification audit in accordance with the appropriate timelines and standards. Submit the audit report to Enform and engages in the Enform audit QA review process as required. Applicable governing bodies will: Review COR/SECOR requests from Enform. Identify any issues that may delay/prevent the COR/SECOR may not be issued. Issue approved COR/SECOR certificates and sends to Enform for distribution. Revoke the certification status of any COR or SECOR holder that does not successfully complete the required annual maintenance audit or approved maintenance option. 6.2 Three Year COR/SECOR Approved: June 12, 2013 Page 4 of 5

157 Enform will: Capture the initial employer and audit scope information at the time of audit registration and confirms this information at the time of audit report submission. Audit registration is only required for COR audits and SECOR external audits. Ensure all requirements for certification have been met as part of the Enform audit QA review process. Apply to the appropriate governing body for employer certification and forwards certificates it receives from the governing bodies to employers upon their arrival at Enform. Implement a process to obtain signatures of sponsoring partners (CAPP, PSAC, CAODC, EPAC, CEPA and CAGC). Produce certificates and forwards these to employers directly if they fall outside the jurisdiction of governing bodies that issue their own certificates. Capture all critical information for every certificate issued in a database. o This includes certificate date/last day on site, legal and trade name(s), WCB account number(s), industry code(s)/classification unit(s), and for site specific audits in Alberta only, the appropriate site name. o Certificate information is also linked to additional certification audit information. Include the employer s legal name, certificate number and type, and date of expiry on the list of COR and SECOR holders on the Enform website (unless requested to do otherwise by the employer). Initially inform employers of the need to maintain their certification annually as well as providing timely reminders of maintenance requirements. Inform governing bodies and/or revokes the certification status of any COR or SECOR holder that does not successfully complete the required annual maintenance audit/assessment or approved maintenance option. Remove any employer that fails to maintain their audit/assessment or who has their certificate expire without providing a new certification audit from the list of COR and SECOR holders on the Enform website. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 6.2 Three Year COR/SECOR Approved: June 12, 2013 Page 5 of 5

158 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 6.3 Six-Month Certificate of Recognition Background A Six-Month COR can be issued to employers in the regular COR program who are seeking recertification without active worksites or where their current activity level is too low to be representative of their operations. In these situations, employers have the option of conducting an administrative audit, which, if successful, will make the employer eligible for a Six-Month COR. Policy The Six-Month COR is not available to employers seeking COR certification for the first time The Six-Month COR is not available for employers in the SECOR program as there is no requirement for active worksites when completing the SECOR Audit To be eligible for a Six-Month COR, an employer must: Hold a COR that is about to expire or has expired within the last three months Be facing one of the following situations: Their recertification audit is scheduled for a period when their operations and workforce levels are well below average for the employer. They have no active worksites and their COR is about to expire Audits conducted for Six-Month CORs are not eligible for the limited scope audit process The Six-Month COR is granted on the basis of an administrative audit To meet Enform standards, the administrative audit must include: A documentation review of all employers health and safety records as required by Enform s COR Health and Safety Audit Protocol. As many interview and observations as the auditor can reasonably complete. Interview and observation questions that cannot be answered should be marked as not applicable. These score values are then not included in the total possible score The auditor must follow all other standards and procedures for COR Certification/Recertification Audits and Audit QA Review. This includes the scoring standard of 80% overall and no less than 50% on each audit element. 6.3 Six-Month COR Approved: March 26, 2012 Page 1 of 2

159 6.3.6 Typically, employers only receive a single Six-Month COR before undergoing a full certification audit for a Three-Year COR. Procedure An employer s first Six-Month COR must be conducted by a certified external auditor and may be used to maintain eligibility for provincial rebates, if applicable An employer s second (or subsequent) Six-Month COR may be conducted by an external auditor or by the employer s certified internal auditor An employer s second (or subsequent) Six-Month COR is not eligible for provincial rebates, if applicable. The procedure for the Six-Month COR certification will follow same pattern and requirements as a typical Three-Year COR certification with the following important exceptions: The auditor: Provides a rationale for applying for a Six-Month COR at the time of audit registration and awaits approval for the administrative audit before performing the audit. Performs an administrative audit that is in compliance with Enform s COR Health and Safety Audit Protocol. This type of audit: o Relies primarily on a documentation review. o Includes employee interviews and observations of administrative worksites as available. o Includes any available worksites. o Follows the same time limits imposed on regular COR audits including completion of on-site activities within 45 days and audit report submission within 45 days of the last day on site. Enform: Reviews any audit registration for a Six-Month COR and evaluates the request against the above policy requirements. This includes ensuring the Employer: o Holds a COR that is about to expire or has expired in the last three months. o Is facing a situation in which their next certification audit is scheduled for a period when their operations and workforce levels are well below average and/or their COR is about to expire and they have no active worksites. Performs an audit QA review on the administrative audit that is appropriate to this type of audit. Documents the rationale for issuing the Six-Month COR when processing the completed audit in the provincial data systems as required. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 6.3 Six-Month COR Approved: March 26, 2012 Page 2 of 2

160 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 6.4 One-Year Certificate of Recognition Background A One-Year COR or One-Year SECOR may be issued to allow certification for employers who have undergone a period of rapid growth or employers with a health and safety management system that has not been in place for a full 12 months (required for a regular three year certification). A One-Year COR or One-Year SECOR still requires at least three months of historical documentation. Sometimes employers may experience a situation when due to general economic conditions, their operations are substantially diminished to the point where they have no active worksites, or where their activity levels are so low that representative audits cannot be conducted. In this situation, an employer may apply to Enform for a one-year COR. At the recommendation of Enform and/or a governing body, a One-Year COR or One-Year SECOR may also be issued in situations in which a standard three year certification is not warranted. Policy A One-Year COR or One-Year SECOR is a type of certification that is valid for 12 months following the last day on site of a certification audit A One-Year COR or One-Year SECOR may be issued under the following circumstances: An employer is unable to produce documentation to establish that their health and safety management system has been in place and functional for the twelve months leading up to their certification audit An employer is applying to use out-of-province work sites to gain and/or maintain COR certification An employer is attempting to recertify their COR, but their documentation from the previous year is incomplete and cannot substantiate that their health and safety system has been operating continuously for the minimum one-year period An employer who is attempting to recertify and who typically has active worksites or field operations, may due to general economic conditions, experience a significant reduction in their operations to the point where they have no active worksites, or where their activity level is so low compared to 6.4 One-Year COR Approved: June 14, 2016 Page 1 of 3

161 Procedure their normal business that a representative audit cannot be conducted. In this circumstance an employer may conduct a recertification audit for a One-Year COR with the prior approval of Enform A governing body requests a One-Year COR or One-Year SECOR for an employer that: Has successfully completed a certification re-audit as part of an on site audit review (OSAR) or verification audit process. Has completed serving a penalty of suspension of their COR or SECOR certification A One-Year COR/SECOR may serve as a probationary measure in cases where audit irregularities and/or other problems suggest a three year certification is inappropriate. In these cases, Enform may recommend to the governing body that an employer receives a One-Year COR or One-Year SECOR. Under these circumstances, the governing body would provide final approval for a One-Year COR or One-Year SECOR based on the recommendation put forward by Enform In order to be eligible for a One-Year COR or One-Year SECOR, at least three months of audit documentation (policy documents and records) is required Enform shall retain records on the rationale for issuing and/or requesting a One- Year COR/SECOR and provide this rational to the governing bodies where required. Employers may: Seek a One-Year COR or One-Year SECOR if they have at least three months of audit documentation (policy documents and records). Auditors must: Identify situations where a One-Year COR or One-Year SECOR will apply at the time of audit registration. Governing bodies may: Issue a One-Year COR or One-Year SECOR as an outcome of the OSAR or verification audit process. Issue a One-Year COR or One-Year SECOR as an outcome to a certification audit following a suspension of COR or SECOR certification. Enform will: Verify that requests for a One-Year COR or One-Year SECOR meet the criteria outlined in the policy above. Recommend to the governing body or bodies that a One-Year COR or One-Year SECOR be issued to a given employer. 6.4 One-Year COR Approved: June 14, 2016 Page 2 of 3

162 Maintain a record of the rationale for providing a One-Year COR/SECOR. o This will be filed as a part of the certification registration with the relevant governing body. Issue (as applicable) a COR or SECOR certificate that expires twelve months after the last day on site of the certification/recertification audit. Remind employers receiving a One-Year COR of their requirement to carry out a certification audit the following year in order to maintain their COR/SECOR status. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 6.4 One-Year COR Approved: June 14, 2016 Page 3 of 3

163 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 6.5 Medium Employer Certificate of Recognition (MECOR) Process Background The Medium Employer Certification of Recognition (MECOR) process provides small employers in the SECOR program and new employers with less than 20 employees a graduated process for achieving a regular COR. With this process, employers undergo a SECOR External Audit for certification followed by two maintenance years in which the regular COR audit protocol is applied. Policy The MECOR process is available to: Existing Enform SECOR holders. Existing Enform SECOR holders who have grown beyond Enform s standard of 10 employees or less for SECOR eligibility are still eligible for the MECOR process if they have less than 20 employees when performing their first MECOR process audit. Employers who are new to the COR Program who have less than 20 employees. The owner(s) and any person covered by the employer s WCB account are included in the number of employees If at any point in the MECOR process an Employer exceeds 30 employees, they would transition out of the MECOR process and perform a COR Certification Audit for their next scheduled audit The following Employers are not eligible to participate in the MECOR process: Any Employer who currently holds or has ever held a regular COR. Any Employer who has completed a full MECOR cycle. Any Employer who has been failed to meet the MECOR standard while in the MECOR process The MECOR process is completed over a three-year cycle: Year One: A SECOR External Audit is conducted that follows all the policies and procedures for a SECOR External Audit including: The requirement that the owner, most senior operational person, or an employee familiar with the overall work operation successfully complete the Enform Safety Program Development Course. The requirement to use an Enform Certified External Health and Safety Auditor. 6.5 MECOR Process Approved: September 29, 2011 Page 1 of 4

164 Procedure The audit must score at least 80% overall and at least 50% in each element. The Employer receives a SECOR certificate following a successful audit that remains valid for the remainder of the MECOR process if successfully maintained. Year Two: A COR Maintenance Audit is conducted using either an External or Internal Enform Certified Health and Safety Auditor. This audit follows the policy and procedure for a COR Maintenance Audit with two exceptions: Unique MECOR scoring requirements are applied the audit must score at least 50% overall. The Employer maintains their SECOR certificate. Year Three: A COR Maintenance Audit is conducted using either an External or Internal Enform Certified Health and Safety Auditor. This audit follows the policy and procedures for a COR Maintenance Audit with two exceptions: Unique MECOR scoring requirements are applied the audit must score at least 70% overall and at least 50% in each element. The Employer maintains their SECOR certificate. In advance of registering for the MECOR process: Enform: Discusses the suitability of the MECOR process with SECOR Employers experiencing or projecting growth or with Employers with less than 20 employees interested in entering the COR program. Applies the above policy in determining the eligibility of the Employer for the MECOR process. In advance of registration of their first audit in the MECOR process: The Employer: Has the owner, most senior operational person, or an employee familiar with the overall work operation complete the Enform Safety Program Development Course. o If the Employer is already in the SECOR Program and has met the Enform Safety Program Development Course and Refresher Course requirements, they may proceed into the MECOR process without repeating the Enform Safety Program Development Course. 6.5 MECOR Process Approved: September 29, 2011 Page 2 of 4

165 In Year One of the MECOR Audit Cycle: The Auditor: Enform: Registers an External SECOR Audit on behalf of the Employer with Enform. Performs a SECOR External Audit for the Employer as per the policy and procedure governing this type of audit. Performs a QA Review on the External SECOR Audit and approves/rejects the audit as per the policy and procedure for this type of audit. o The scoring requirement for certification with this audit is a minimum of 80% overall and at least 50% in each Element. Awards or recommends the appropriate governing body award a Three Year SECOR certificate to those Employers who succeed in their External SECOR Audit. In Year Two of the MECOR Audit Cycle: The External or Internal Auditor: Enform: Registers a COR Maintenance Audit on behalf of the Employer with Enform. Performs COR Maintenance Audit for the Employer as per the policy and procedure governing this type of audit. Performs a QA Review on the COR Audit and approves/rejects the audit as per the policy and procedure for this type of audit. o The scoring requirement for certification with this audit is a minimum of 50% overall. o Records the successful maintenance of the Employer s SECOR Certification for all approved audits. In Year Three of the MECOR Audit Cycle: The External or Internal Auditor: Registers a COR Maintenance Audit on behalf of the Employer with Enform. Performs COR Maintenance Audit for the Employer as per the policy and procedure governing this type of audit. 6.5 MECOR Process Approved: September 29, 2011 Page 3 of 4

166 Enform: Performs a QA Review on the COR Audit and approves/rejects the audit as per the policy and procedure for this type of audit. o The scoring requirement for certification with this audit is a minimum of 70% overall and at least 50% in each Element. Records the successful maintenance of the Employer s SECOR Certification for all approved audits. Informs the Employer of their completion of the MECOR process and the necessity to perform a COR Certification the following year to maintain their COR status. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 6.5 MECOR Process Approved: September 29, 2011 Page 4 of 4

167 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 6.6 Injury Management/Return-to-Work Certification Background Injury Management/Return-to-Work (IM/RTW) programs are a way for employers to help injured workers stay at work or return to productive and safe employment as soon as physically possible after a work-related accident. Enform offers IM/RTW certification to any employer with a current COR (or as part of an initial COR certification audit) who successfully completes an IM/RTW certification audit. Thereafter the IM/RTW certification follows the same pattern of three year certification and annual maintenance as the employer s COR certificate. In British Columbia, employers who are successful in their IM/RTW certification audit and maintain it annually are eligible to receive an additional 5% rebate on their previous year s WCB premiums. Policy In order to be eligible for IM/RTW certification, an employer must: Have 11 or more employees Hold current COR certification or be in the process of achieving COR certification with a COR certification audit Have their IM/RTW certification audit carried out by an Enform certified auditor that has completed their Enform training on the IM/RTW protocol Have their IM/RTW certification audit meet all the timelines and standards of the IM/RTW audit (see 3.21 Injury Management/Return-to-Work Audit) Score at least 80% overall on the IM/RTW certification audit and no less than 50% on each audit element Have their IM/RTW certification audit successfully pass the Enform audit QA process An employer that meets the above criteria can carry out their initial IM/RTW audit for certification at any point. However, the following year the IM/RTW audit will be conducted alongside the COR audit and follow the certification/maintenance pattern of the COR certification The IM/RTW certification must cover the same WCB accounts, industry code(s), and scope of operations as an employer s COR certification Employers with multiple COR certificates due to multiple WCB accounts or operating across multiple provincial jurisdictions may limit the IM/RTW certification and maintenance to one or more of their COR certificates. 6.6 Injury Management/Return-to-Work Certification Approved: March 26, 2012 Page 1 of 2

168 6.6.4 The IM/RTW certificate is maintained alongside an employer s COR certificate. The employer: An Enform certified internal auditor is eligible to perform the IM/RTW maintenance audit if they have completed Enform training on the IM/RTW audit The IM/RTW maintenance audit does not have a minimum scoring requirement. However, it must pass then Enform audit QA review process. Contracts the services of an Enform certified external auditor who has completed Enform IM/RTW audit training. Has either a stand-alone IM/RTW certification audit or IM/RTW certification audit alongside their COR audit. The external IM/RTW auditor: Provides the required employer and audit scope information both at registration and upon report submission to ensure all required information for certification purposes is accurately captured. Performs an IM/RTW certification audit in accordance with the appropriate timelines and standards. Submits the audit report to Enform and engages in the Enform audit QA review process as required. Enform: Captures IM/RTW audit scope information at audit registration and confirms this information at audit report submission. Ensures all requirements for certification have been met as part of the Enform audit QA review process. Applies to the appropriate governing body for the employer s IM/RTW certification and forwards certificates from the governing body to employers upon their arrival at Enform. Produces certificates and forwards to employers directly if they fall outside the jurisdiction of governing bodies that issue their own certificates. Captures and maintains all critical certificate information for every IM/RTW certificate issued in a database. Revokes the IM/RTW certification status of any COR holder that does not successfully complete their COR or IM/RTW annual maintenance requirements. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 6.6 Injury Management/Return-to-Work Certification Approved: March 26, 2012 Page 2 of 2

169 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 6.10 Amendments to Certificates Background COR amendments based on simple changes (such as a new legal name, WCB account number, or industry reclassification) may be granted by Enform and processed in the governing bodies online system or by request. More fundamental changes to an employer s operation may invalidate the original COR, since the certifying audit would no longer be representative of the employer s operation and/or management structure. Examples of changes that may warrant re-certification of an employer s health and safety management system include: Policy acquisition of another company; merger with another company; addition of another division with a different industry; addition of new facilities, or management restructuring Employers whose operations have undergone a change may submit a written request to Enform to amend their previously issued COR and issue a revised certificate. (See Appendix COR Amendment Form) Enform is responsible for determining whether the requested amendment is a simple change, a fundamental change that will invalidate the current COR, or a situation where an existing COR may be transferred following the sale of a business (see section ) Employers determined to have undergone a simple change to their business will be issued a new certificate with the new name, account number, and/or industry code(s)/classification unit(s) The new certificate will be re-issued only for the parts of the organization that were included under the original certification audit The new certificate will retain the original expiry date Amendments to Certificates Approved: June 3, 2013 Page 1 of 3

170 Employers who have been reclassified by the WCB without a change to their operations, and assigned a new industry code or classification unit may not be required to send in a request for amendment unless clarification of information is required. This type of amendment may be handled by Enform and the WCB Employers that have acquired or merged with another company may be considered to have undergone a fundamental change, and may be required to complete a new external audit that encompasses the new scope of their business if the change to their structure includes: new employees; new management structure; new operations; new industry code or classification unit (except as assigned in section ); new facilities; or new division(s) Notwithstanding section , in certain circumstances a new owner who acquires an operating business with a COR may be allowed to transfer that COR without conducting a new certification audit, if the following conditions are met: The new owner commits to maintaining the existing health and safety management system The key management and health and safety employees responsible for the functioning of the existing health and safety management system remain in place after the sale The previous business operations continue essentially unchanged and can be clearly distinguished from any other operations that may be conducted by the new owner The scope of the new COR will be unchanged from that established by the previous certification audit The new owner commits to meeting Enform s COR maintenance requirements established by the original certification audit Should an employer believe that their COR status is inaccurate, they may request that Enform amend their COR COR amendments requested by an employer will be investigated jointly by the governing bodies and Enform Should the employer s concerns be substantiated, Enform will follow the amendment process, as required Amendments to Certificates Approved: June 3, 2013 Page 2 of 3

171 Procedure The employer will: Provide the necessary documented evidence outlining/describing the change using Appendix COR Amendment Form. Enform will: Receive and review documented evidence outlining/describing the change from the employer. Assess the documented evidence and determine whether the change is a simple change, a fundamental organizational change or a situation where an existing COR may be transferred to the new owner following the sale of a business. Follow the process to jointly approve amendments to existing CORs with the governing bodies. Ensure that certificates are not issued to any part of the employer's operations that have not been included in the original audit. Submit the request into the online system or by to the governing bodies, including a notation to outline/describe the change to the organization and the reason for granting the change. Enform will retain the employer s original request and documentation in the employer s file and if necessary, provide copies for review by the governing bodies. Notify the employer regarding the outcome of the request. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 6.10 Amendments to Certificates Approved: June 3, 2013 Page 3 of 3

172 ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE: 6.11 Changing Certifying Partners Background In order to obtain a COR/SECOR, an employer must select a certifying partner (CP) from the list approved by the provincial governing body. Enform is the CP for Canada s upstream oil and gas industry. It is recommended that employers choose their CP based on industry alignment. However, any employer may make a request to change CPs at any time. This process may alter slightly depending on the provincial jurisdiction. In British Columbia (BC), the governing body assigns employers to a CP based on industry type. Where questions arise concerning which CP is appropriate, the governing body will make a determination on the basis of natural alignment. Outside the province of BC, employers are free to choose any CP that is willing to provide certification services to them. There may be circumstances where employers have their COR/SECOR certification from one CP and wish to have Enform serve as their CP. Conversely, employers with COR/SECOR certification through Enform may wish to change their CP. Policy In the province of British Columbia (BC), an employer wishing to change certifying partners (CP) must first gain the approval of the BC governing body Any requests for a change of CP received by Enform from a BC company will be managed in consultation with the BC governing body Employers approaching Enform to be their CP who already have a valid COR or SECOR issued by another CP must: Demonstrate alignment with the oil and gas industry Successfully complete a certification audit performed by a certified Enform external auditor or SECOR assessor (for small employers). For SECOR holders, this will entail completing all required educational requirements Changing Certifying Partners Approved: March 26, 2012 Page 1 of 3

173 Enform will continue to list employers that express their intention to transfer to another CP as COR/SECOR certificate holders with Enform in the database and the published online list until either: The new CP provides written confirmation that they are now serving as this employer s CP, or The employer s COR or SECOR with Enform expires Whether an employer is seeking transfer to Enform as their CP or departing Enform, Enform remains committed to full written notification between all stakeholders in any transfers between CPs. Procedure Stakeholders include the previous CP, the new CP, and any governing bodies. For employers transferring to Enform as their CP The employer: If a BC company, contacts the BC governing body to confirm they may transfer to Enform as their CP. Provides a written request to Enform to have Enform serve as their CP. o This request must include an explanation as to how the employer is aligned with the oil and gas industry Submits a letter of notification to their existing CP indicating their intention to change CPs. Provides a copy of the letter of notification to Enform. Completes any required course work in preparation for Enform COR/SECOR certification. Performs a certification audit with Enform. Enform: Receives the CP change request from the employer. If a BC company, contacts the BC governing body to confirm the employer has received permission to transfer to Enform as their CP. Evaluates employer s alignment with the oil and gas industry. o If an employer is in no way aligned with the oil and gas industry, Enform may direct the employer to a more appropriate CP. Processes and reviews the employer s certification audit. Upon successful completion of the certification audit, registers the results with the respective governing bodies so that the employer receives an Enform COR/SECOR with a new expiry date. Provides the previous CP and the governing bodies (as required) with a letter of notification that the employer is using Enform as their COR/SECOR CP Changing Certifying Partners Approved: March 26, 2012 Page 2 of 3

174 For Enform employers transferring to another CP The employer: Provides a written notification to Enform of their intent to change CPs. Enform: Confirms receipt to the request to transfer to another CP. o If a BC company, Enform may also notify the employer of the requirement to consult with the BC governing body. Cancels the employer s COR/SECOR certificate and removes the employer from its online list of COR/SECOR certificate holders once written confirmation is received that the employer is certified with the new CP. Approval Juliet Goodwin, CRSP Manager, Safety Audits and Certifications 6.11 Changing Certifying Partners Approved: March 26, 2012 Page 3 of 3

175 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 6.13 Fraudulent Certificates Background If an employer misrepresents their COR status in any way, they may face penalties imposed by the appropriate governing body, including the cancellation of any existing COR(s) held by the employer. In certain cases employers have been known to modify the expiry dates on their COR, or create a counterfeit COR in order to bid for contracts. To maintain the integrity of the program, the governing bodies have committed to investigating incidents of employer modified CORs, as well as any other employer activities that involve misrepresentation of an employer s COR status, or eligibility for that status. The governing bodies may impose specific penalties on an offending employer, including the cancellation of CORs for all accounts and industries under their ownership. As a certifying partner, Enform has a responsibility to bring any occurrences of fraudulent certificates to the governing bodies attention. Policy This section applies to all COR holders of all types, including: COR, MECOR and SECOR Enform will forward to the appropriate governing body any concerns raised regarding any employer who may have misrepresented their COR status or their eligibility for COR status All concerns reported must be in writing (letter or ) and the complainant s name must be included If an individual wishes to raise their concerns anonymously, the caller will be directed to Enform s call centre or call centre Enform and the appropriate governing body will conduct an investigation into allegations that an employer may have: altered their COR in any way; forged a COR; misrepresented a cancelled COR as active; inappropriately influenced the audit results of their certification audit; or misrepresented the number of individuals covered under their account to qualify for SECOR or MECOR Fraudulent Certificates Approved: June 10, 2013 Page 1 of 3

176 If it is determined that an employer has carried out any of the actions listed in , the following penalties may apply for a first occurrence Any COR(s) currently held by the employer will be cancelled, and the employer will be struck from the list of COR holders on the Enform and governing bodies website. This includes CORs for all accounts and industries under the ownership of the employer. If the COR was issued as part of a group audit of related companies, the penalties will apply to all CORs issued under the original group audit The employer will be ineligible to apply for COR recertification for a period of up to one year from the date of the decision All CPs and the appropriate WCB will be advised of the employer s name and the penalty imposed If it is determined that an employer has carried out any of the actions listed in for a second time, the penalties listed under will apply with the following additional specification The employer will be ineligible to apply for recertification for a minimum of two years Once an employer s suspension period has elapsed, they will be eligible to conduct a certification audit if Enform or another CP is willing to accept them into their program. If the audit meets governing bodies standards for COR certification, the new COR will be limited to a one-year certificate. The employer will be eligible for a normal three-year certificate on subsequent recertification audit If the employer applies for certification before the end of their suspension period, the application will be denied Should an employer attempt to evade the original penalty imposed (e.g. by changing their corporate name, or incorporating a second company to take over business operations) the incident will be treated as a second occurrence. Procedure The complainant will: Submit their concern to Enform in any of the following ways: o Complete the complaint forms posted on the Enform website (Appendix S: Stakeholder Complaint Form) and submit to Enform for review. o Submit an to corinfo@enform.ca outlining the concerns. o Call the Enform COR call centre to report any concerns Fraudulent Certificates Approved: June 10, 2013 Page 2 of 3

177 Enform will: Review the concerns and provide any necessary information to the appropriate governing body in relation to the reported issue of misrepresentation of COR status. Document and track any decision made by the appropriate governing body that effects the COR status of an employer. Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 6.13 Fraudulent Certificates Approved: June 10, 2013 Page 3 of 3

178 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 6.14 Employer Review Background A COR is issued to an employer whose health and safety management system meets the governing body standards for a COR as determined through an external audit (or SECOR assessment if enrolled in the SECOR program). Within the province of Alberta, to maintain the integrity of all CORs, Partnerships will investigate should any of the following situations occur to an employer who holds a COR: Workplace fatality, serious injury or incident or is issued multiple stop-work orders for imminent danger by Alberta OHS. Identified on the Employer Injury and Illness Prevention Program (EIIPP) and has held a COR for 4 years. An Alberta Occupational Health and Safety Office (OHS Officer) identifies violations of the Occupational Health and Safety Code. Knowingly misrepresented the reporting of worker injuries as required by the Workers Compensation Act. When any of the circumstances described above occur to an employer who holds a COR, it may be an indication that significant deficiencies exist in their health and safety management system, and must be corrected. Policy The provisions of Employer Review apply to all Alberta COR holders of all employer types, including regular COR holders, SECOR holders, and employers certified under the Medium Employer program (MECOR) When an Employer Review is initiated with an employer, their COR status will be considered Under Review by Partnerships and any related incentives may be placed on-hold during the period of review If an employer fails to satisfactorily complete improvement activities such as an action plan audit as required, the following processes may be followed Where Enform has indicated that they do not want to be involved in the decision process, Enform will be copied on the letter notifying the employer that their COR will be cancelled Where Enform has indicated that they want to be involved in the decision process, the Executive Director OHS will meet with Enform. Where agreement has been reached with Enform, the employer s COR will be cancelled Employer Review Approved: April 3, 2013 Page 1 of 2

179 When a COR is cancelled, the employer will be notified in writing by the Executive Director and will be given a 60-day grace period before the COR cancellation is implemented Any related incentives will be forfeited for the calendar year in which the COR was cancelled (should the Employer Review process cross calendar years, the PIR rebate that was placed on hold in the first year of the process will be released to the employer, and the rebate from the second year will be forfeited) If the employer fails to complete their external audit within the timelines required, or the external audit does not meet Partnerships standards required for certification, the Executive Director will order the cancellation of the employer s current COR Employers and/or Enform may appeal a COR cancellation as a result of a failed action plan through an arbitration process If the employer is charged under the Occupational Health and Safety Act, any incentives will be placed on-hold for the year in which the charges are laid. If the employer is convicted, they will forfeit their incentive. If charges are withdrawn or the employer is found not guilty, the employer will be eligible to receive their incentive This provision will not apply if the employer has already forfeited their incentive for the same matter through the Employer Review process. Procedure Enform will: Track all letters sent to employers and Enform regarding Employer Reviews within the database system. When the employer requests will: o Attend Employer Review meetings. o Assist with action plan development. Partnerships will: Implement one of the Employer Review processes as described in Partnerships Operational Policies 10.8 Employer Review. Follow all procedures outlined in Partnerships Operational Policies 10.8 Employer Review Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 6.14 Employer Review Approved: April 3, 2013 Page 2 of 2

180 ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE: 7.1 Health and Safety Program Fee Structure Background The management and administration of Enform s COR/SECOR program is partially funded by oil and gas employers through their WCB premiums in Alberta and Saskatchewan. A similar WCB funding model is in place in British Columbia (BC) however this model is not related to the employer s industry type. The companies that are funding the COR program through their WCB premiums are considered members of Enform. Policy Enform charges an annual fee to employers for COR related services (see tables below). COR/SECOR fees are payable at the time of audit registration or audit submission in the case of SECOR assessor audits The below annual fees will be charged to member employers that fit into the following criteria: Member employers in Alberta and Saskatchewan that have an Enformassigned WCB industry code Member employers that operate exclusively in British Columbia: WorkSafeBC s COR base funding model is not tied to classification units and Enform receives funding through WorkSafeBC for every COR/SECOR holder in British Columbia. British Columbia -based companies that also operate outside of the province may be subject to the annual fee depending on the WCB industry code(s) they carry in those provinces A list of Enform-assigned WCB industry codes in Alberta and Saskatchewan can be found in Appendix A. Annual Member Fee Audit Type SECOR (1-10 employees) COR (11+ employees) PASE Gap Analysis Fee** Annual Fee $150 +applicable taxes $250 +applicable taxes $2500 +applicable taxes 7.1 Health and Safety Program Fee Structure Approved: June 3, 2013 Page 1 of 2

181 7.1.2 The following annual fees will be charged to non-member employers that fall into the following criteria: Non-member employers in Alberta and Saskatchewan that do not have an Enform-assigned WCB industry code Any employers operating outside of Alberta, Saskatchewan, or British Columbia. Annual Non-Member Fee Audit Type SECOR (1-10 employees) COR (11+ employees) PASE Gap Analysis Fee** Annual Fee $500 +applicable taxes $1000 +applicable taxes $5000 +applicable taxes **If PASE gap analysis is not required, the employer will be charged at the standard COR rates. Procedure Enform will: Notify new employers of Enform s COR fee structure. Invoice new or existing employers, who fall outside of the Enform-assigned industry codes, prior to a new audit registration being approved or prior to accepting a submitted SECOR audit. Invoice member employers are invoiced at time of audit registration or audit submission (SECOR). Approval Melissa Mass, BAIE, NCSO, CRSP Manager, Safety Audits and Certifications 7.1 Health and Safety Program Fee Structure Approved: June 3, 2013 Page 2 of 2

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