certificate of recognition

certificate of recognition Small Business Audit Document / Version 1.0 www.bccsa.ca BC Construction Safety Alliance 2010

BC Construction Safety Alliance (BCCSA) The BC Construction Safety Alliance (BCCSA) is a non-profit organization that is owned and operated by British Columbia s construction industry. Acknowledgements BCCSA acknowledges the Alberta Construction Safety Association, the Canadian Federation of Construction Safety Associations, and WorkSafeBC for their assistance in developing this audit document. Disclaimer The information presented in this publication is intended for general use and may not apply to every circumstance. This is not a definitive guide to government legislation, and it does not relieve persons using this publication from their responsibilities under applicable legislation. BCCSA does not guarantee the accuracy of, and does not assume liability for, the information presented. Individual counselling and advice is available from BCCSA. Copyright This publication is the property of BCCSA. Reproduction in any form, by any means, in whole or in part, or use of this publication for other than the BC Construction Safety Alliance is prohibited without the express written consent of the BC Construction Safety Alliance. BC Construction Safety Alliance 625 Agnes Street, Suite 400, New Westminster, BC V3M 5Y4 t: 604.636.3675 f: 604.636.3676 tf: 1.877.860.3675 w: www.bccsa.ca email: cor@bccsa.ca

TABLE OF CONTENTS Part 1: Introduction to Small Business Audits...2 Definitions...4 Instructions for Completing the Small Business Audit Document...6 Completion Instructions...7 Observation Checklist...8 Part 2: Small Business Audit Document...9 Audit Information Sheet...11 List of Active Worksites Sheet...12 Optional Injury Management/Return to Work Audit...31 Audit Score Sheet...35 How to Complete the Auditor Executive Summary Report...36 Auditor Executive Summary Report...37 Corrective Action Plan...38 Code of Conduct & Ethics...40 Audit Submission Checklist...41 BCCSA Small COR Audit Document - Version 1.0 1

BCCSA Small COR Audit Document - Version 1.0 2

Part 1: Introduction BCCSA Small COR Audit Document - Version 1.0 3

DEFINITIONS Accident or Incident An unplanned, undesired event that results in property or equipment damage, injury, death, or occupational illness. Auditor An individual who has the qualifications and skills to measure health and safety performance against a given standard. Competency is based on training through a recognized agency, certification, and experience. Competent person A person whom has received specific training or has intimate knowledge, possibly gained from years of work experience. Critical Task A task that has the potential to produce major loss to people, equipment, process, and/or the environment. Element A section within the health and safety program that deals with a specific component of the management system. This can be an audit element and/or sub-element. Job A segment of work, a specific work assignment, a set of actions required to complete a specific work objective. An accumulation of all tasks involved at the worksite. Management Person(s) who have some level of authority, responsibility, and accountability within the firm. Manager The most senior individual in the organization. This may be the owner, president, or general manager. This is the individual who must accept ultimate responsibility for the organization s health and safety program and sign all policies. Medical Monitoring (Surveillance) Mandated medical examinations for workers exposed to occupational health hazards such as organic lead, asbestos, silica, coal dust, noise exposure, etc. Refer to Occupational Health and Safety legislation for your jurisdiction. Musculoskeletal Injury An injury or disorder of the muscles, tendons, ligaments, joints, nerves or soft tissue (i.e. sprain, strain and inflammation) that can be caused or aggravated by work. BCCSA Small COR Audit Document - Version 1.0 4

Near Miss An unplanned and undesired event that under slightly different circumstances could have resulted in property damage or personal injury or occupational disease (i.e. close call). Prime Contractor The contractor, employer, or other person who enters into an agreement with the owner of the worksite to be the prime contractor. The prime contractor has the overall responsibility for health and safety on the worksite. Rule A company directive that governs and controls conduct or action. Safe Job Procedure A written, specific step-by-step description of how to complete a job safely and efficiently from start to finish. Safe Work Practice A set of positive guidelines or Do s and Don ts on how to perform a specific task or how to deal with a specific situation that may not always be done in a certain way. Subcontractor An individual or company hired by a general or prime contractor to perform a specific task as part of the overall project. Supervisor An individual who directs the day-to-day work. This includes foremen, supervisors, and in some firms, superintendents. This person is included in the management interview questionnaire. Task A segment of work that requires a set of specific and distinct actions for its completion. Worker An individual employed by a company (full-time, part-time, volunteer or on a contractual basis). This could include owners, management, sub-contractors. For the purposes of this audit, a worker will be defined as an individual who does not have management or supervisor responsibilities. BCCSA Small COR Audit Document - Version 1.0 5

1. INSTRUCTIONS FOR COMPLETING THE SMALL COR AUDIT DOCUMENT BCCSA has provided this Small COR Audit Document to help construction companies measure the effectiveness of their health and safety management systems. This document is designed to be used by company staff members or other individuals trained in its use. Before you begin the health and safety audit process, read these pages carefully. They explain the reasons for audits, and describe some of the techniques used. Audits are a management tool used to improve existing systems. Audits measure system performance and provide a basis for future management strategies. It is important for auditors to be objective at all times; otherwise, the audit process is of little use. Note: All audits, from start to completion, must be completed within a maximum of 45 days. The audit must then be finalized and submitted to the BCCSA within 45 days of this audit completion date. Auditor Requirements Auditors must provide a comment for every question in the audit document, regardless of whether it is a positive, negative, or not applicable (N/A) response. One-word comments do not convey adequate information; ensure that comments provide insight into the points awarded. Auditor comments must support how the auditor arrived at a positive, negative, or N/A score by noting where documentation was located (i.e., office file, supervisor s truck, or site trailer), what was observed (i.e., training records showed, or observed one worker not wearing a hard hat), or by summarizing documentation or interview comments (i.e., policy statement is signed (date) by (name) who is currently the company s president, or all employees understood and were able to repeat wording from the company health and safety policy ). Where there is an increase or decrease in the score from the previous audit, comments should explain what occurred to cause the score to change. Sufficient space has been provided to allow for auditor comments after each question. BCCSA Small COR Audit Document - Version 1.0 6

COMPLETION INSTRUCTIONS This audit document must be completed in ink. Read each question and verify whether the answer is Yes or No. Questions are verified through site observations and documentation review. SUPPORTING DOCUMENTATION Examples of supporting documentation are listed below: Safe Work Practices Safe Job Procedures Safety Board Tailgate Meeting Minutes Accident/Incident Logs Health and Safety Minutes Orientation Records Records and Statistics Other NOTE: Most of these documents should be available in your Health and Safety Manual. Please enclose a copy of your health and safety manual with the completed audit document. A comment is required for EVERY question. If the question is answered No, provide corrective action plan steps for improvement in the comments section. BCCSA Small COR Audit Document - Version 1.0 7

OBSERVATION CHECKLIST If both observation and documentation verification are required for one question, you must have both forms of verification in order to answer the question as Yes. Audit Question Positive Negative 2.5 Are controls implemented to prevent identified hazards from reoccurring? 3.1 Do the safe work practices reflect the company s activities? 3.3 Are the safe work practices readily available? 3.5 Are safe job procedures followed? 3.6 Are safe job procedures readily available? 5.3 Is appropriate PPE used where hazards exist? 7.6 Are copies of the Workers Compensation Act and BC Occupational Health and Safety Regulations readily available? 10.3 Is there adequate first aid personnel and equipment available? 11.3 Are first aid treatment records kept? BCCSA Small COR Audit Document - Version 1.0 8

Part 2: Small Business Audit Document BCCSA Small COR Audit Document - Version 1.0 9

BCCSA Small COR Audit Document - Version 1.0 10

SMALL BUSINESS AUDIT INFORMATION SHEET FOR COMPANIES WITH FEWER THAN 20 EMPLOYEES Date of Audit: Legal Company Name: Address: City/Town: Province: Postal Code: E-mail Address: Phone Number: Fax Number: WCB Account #: Industry Code(s): Number of Workers at Peak Periods: Number of Workers currently: Auditor Name: Certificate Number: BCCSA Small COR Audit Document - Version 1.0 11

List of active worksites Auditors must list all worksites that are active at the time of the audit, and the numbers of site personnel that were on each worksite. Next, indicate by the means of a checkmark ( ) which ones were visited. This will verify an up-to-date summary of the company at the time of the audit. If there are more worksites than the page has allowed for, please attach a list of additional sites. Worksite Location(s) Visited 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. BCCSA Small COR Audit Document - Version 1.0 12

Company health and safety policy GUIDELINES 1.1 Auditors must see a written policy statement on health and safety that is signed by current senior management. 1.2 Policy must include a statement of the employer s commitment to provide a safe and healthy work environment. 1.3 Policy must be kept current and dated. 1. COMPANY HEALTH AND SAFETY POLICY YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 1.1 Is there a policy statement that is signed and currently dated (1 year or less) by the owner or upper/seniormanagement? 1.2 Does the policy statement include goals? 1.3 Does the policy express a commitment to work in a spirit of consultation and cooperation with the workers? BCCSA Small COR Audit Document - Version 1.0 13

Company health and safety policy cont d GUIDELINES 1.4 The policy must outline the commitment of the company to work with their personnel to promote a health and safe work environment. 1.5 Check documentation to ensure that the policy is reviewed by management every year. 1. company Health and Safety policy YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 1.4 Does the policy statement include the responsibilities or all parties involved? (managers, supervisors, workers etc.) 1.5 Is the policy reviewed annually by management? BCCSA Small COR Audit Document - Version 1.0 14

Workplace hazard assessment and control GUIDELINES 2.1 All workers/jobs/tasks must be assessed in order to identify existing or potential hazards before work starts. The assessment should be based on the work to be performed and result in the identification and implementation of control measures to prevent worker exposure and contamination. 2.2 Documentation must show that the hazard assessment process is continual: performed prior to new projects, changes to job description, introduction of new equipment, etc. 2.3 Review hazard assessments to ensure they re showing timely corrective actions to identified hazards. If no hazards occurred, check the policy to ensure that the process is clearly outlined. 2. workplace hazard assessment and control YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 2.1 Is there a policy outlining that written hazard assessments are conducted? 2.2 Are on-going hazard assessments conducted? 2.3 Do completed hazard identification forms indicate that corrections were done in a timely manner? BCCSA Small COR Audit Document - Version 1.0 15

Workplace hazard assessment and control cont d GUIDELINES 2.4 Review documentation to see that identified hazards are prioritized based on risk/severity/frequency. 2.5 Check hazard assessments to see what controls were required and than walk around to see if those controls were put in place. If they are not in place yet, are they in the process of being implemented, if so than mark yes. Health and Safety Program Verification YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 2.4 Do completed hazard forms show that hazards were prioritized? 2.5 Are controls implemented to prevent identified hazards from reoccurring? BCCSA Small COR Audit Document - Version 1.0 16

Written Instructions GUIDELINES 3.1 Review safe work practices and observe site work to ensure that they reflect current work activities. 3.2 Ensure that required safe work practices are completed. If not, identify missing practices in comments and check No. Verify that a review process is in place. Check orientations, health and safety minutes etc. to confirm that a review process is in place. Should be revised at least annually or when the site changes or new equipment is added. 3.3 Applicable written instructions must be readily available at each worksite and their location should be identifiable through observation and/or documentation. 3. Written Instructions YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 3.1 Do the safe work practices accurately reflect the company s activities? 3.2 Are safe work practices current (within last year)? 3.3 Are the safe work practices readily available? BCCSA Small COR Audit Document - Version 1.0 17

Written Instructions cont d GUIDELINES 3.4 Ensure that safe job procedures reflect activities that the company performs. 3.5 Verify through observation that company employees and subcontractors are working in conformance with the company s safe job procedures. 3.6 Applicable written instructions must be readily available at each worksite and there location should be identifiable through observation and/or documentation. 3. written instructions YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 3.4 Do the safe job procedures reflect the employer s activities? 3.5 Are safe job procedures followed or is corrective action taken? 3.6 Are safe job procedures readily available? BCCSA Small COR Audit Document - Version 1.0 18

Company rules GUIDELINES 4.1 Check documentation to verify that the company rules are in writing. 4.2 Company must have a written progressive disciplinary action process to address non-conformance issues. 4. company rules YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 4.1 Are the company rules clearly stated in writing? 4.2 Are there records outlining disciplinary action for nonconformance or a clear policy in place outlining the process (steps involved)? BCCSA Small COR Audit Document - Version 1.0 19

Personal Protective Equipment GUIDELINES 5.1 Verify that there is a written policy for basic and/or specialized personal protective equipment. 5.2 Look for documentation that the employer has developed or made written instructions readily available to employees with respect to the proper fitting, care and use of PPE such as ear plugs, respiratory devices, fall protection etc. 5.3 Observation and walk around inspections must verify that PPE requirements are being met and the policy is being followed. 5. Personal protective equipment YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 5.1 Is there a written policy for PPE? 5.2 Are there written procedures? (when to wear/replace, application) 5.3 Is appropriate PPE used where a hazard exists? BCCSA Small COR Audit Document - Version 1.0 20

Maintenance Program GUIDELINES 6.1 All equipment which requires ongoing maintenance must be identified. Review equipment records and check for operating/service manuals to ensure that manufacturer and regulatory standards are being met. 6.2 Records should indicate that all equipment is being maintained by recognized service facilities or appropriate documentation/ training records should support qualification of in-house maintenance personnel. 6. maintenance program YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 6.1 Are there current maintenance records for each piece of equipment that requires maintenance according to the policy (manufacturer, legislative/regulatory standards)? 6.2 Is maintenance being done by a competent organization or person? BCCSA Small COR Audit Document - Version 1.0 21

Training and Communication GUIDELINES 7.1 Look for documentation that shows the employer has a health and safety orientation program and/or employees receive orientation if working as subcontractors on a multi employer worksite. 7.2 Check orientation forms to ensure that orientations are conducted before starting work. Anyone who goes through an orientation should retain a copy of completion; this notice of completion should be kept on file. 7.3 Training and testing of competency must be completed before the worker is allowed to work. Evidence that this has occurred could be training records, certificate of qualification, etc. 7. training and communication YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 7.1 Do all employees receive health and safety orientation? 7.2 Are the completed orientation forms that have been both signed and dated? 7.3 Has the company insured that workers are competent in their tasks? BCCSA Small COR Audit Document - Version 1.0 22

Training and Communication GUIDELINES 7.4 Check records to see if supervisors have received any specific health and safety training, specifically around inspections and responsibilities. 7.5 Check documentation (toolbox forms, safety log, etc.) to ensure that toolbox/tailgate meetings are held regularly and attendees names are recorded. 7.6 Review documentation to ensure that a copy of the Workers Compensation Act and Regulation are readily available. 7. training and communication YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 7.4 Has at least one supervisor received training in workplace inspection and health and safety responsibilities? 7.5 Are tailgate/toolbox meetings held regularly and are names of attendees recorded? 7.6 Are copies of the Workers Compensation Act and BC Occupational Health and Safety Regulation readily available? BCCSA Small COR Audit Document - Version 1.0 23

Inspections GUIDELINES 8.1 Verify that there is an inspection policy which covers the frequency of inspections. 8.2 Check documentation to ensure that a standardized checklist is being used for inspections. 8.3 Verify that inspections are being completed at the stated frequency. 8.4 Refer to action forms/logs and/or completed work orders for documentation. 8.5 Verify that all areas of the site are being inspected (i.e. office, shop, storage, facility, active, worksites, etc.). 8.1 Is there a written policy? 8. inspections YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 8.2 Is there a standardized form or checklist used for inspections? 8.3 Confirm that inspection records have been conducted at regular intervals (daily, weekly, monthly) 8.4 Are corrective action forms/logs and/or completed work orders done in a timely manner? 8.5 Are there completed inspections for all tools, equipment and worksites? BCCSA Small COR Audit Document - Version 1.0 24

Investigations GUIDELINES 9.1 Verify that there is an investigation procedure. 9.2 Verify that the investigation policy highlights who incidents/accidents and near misses are reported to. Often it will state that every incident/accident/near miss should be reported to your direct supervisor. 9.3 If no incidents/accidents/near misses have occurred, check to see that there is a policy outlining the requirements to report them all. 9. investigations YES NO 9.1 Is there a written procedure to investigate all incidents/ accidents and near misses? SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 9.2 Does the policy outline who incidents/accidents are reported to? 9.3 Are there records of all incidents/accidents and near misses? BCCSA Small COR Audit Document - Version 1.0 25

Investigations cont d GUIDELINES 9.4 Select a random sample of accident forms to review in order to ensure that corrections have taken place. 9.5 Check records to determine whether the individuals who are completing the investigations have received specific training on investigations. 9. investigations YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 9.4 Have follow-up actions been taken for all incidents/ accidents and near misses? 9.5 Are investigations being completed by a supervisor or worker that is competent in investigation procedures? BCCSA Small COR Audit Document - Version 1.0 26

Emergency Preparedness GUIDELINES 10.1 Verify that there is an emergency response plan (includes fires, earthquakes, spills etc.). In a multi employer worksite the prime contractor is responsible for developing and educating all site personnel on emergency response procedures. 10.2 At a minimum, an emergency response plan should be tested annually. It can be tested more frequently and that could be due, in part, to a request from Prime Contractor or a change in site conditions, etc. 10.3 Look for a completed assessment. Refer to Part 3 of the occupational Health and Safety Regulations. Specifically check Schedule 3-A for minimum levels of first aid. 10. emergency preparedness YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 10.1 Does the company have an emergency response plan? 10.2 Are there records indicating that the emergency response plan is tested for deficiencies? 10.3 Has the company assessed the required First Aid and have those requirements been met? BCCSA Small COR Audit Document - Version 1.0 27

Records and Statistics GUIDELINES 11.1 Review documentation for a policy indicating which records are to be kept and for how long. 11.2 Check documentation to ensure that first aid records are kept for a minimum 3 year period. 11.3 Expect to see data on the type and nature of injuries in order to find areas of concern and/or repeat injuries, If no injuries occurred, policy should indicate a comment to determining root causes. 11. records and statistics YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 11.1 Is there a system for maintaining health and safety records? 11.2 Examine that first aid treatment records are kept. 11.3 Does documentation indicate that records and statistics are being analyzed to determine trends? BCCSA Small COR Audit Document - Version 1.0 28

Records and Statistics CONT D GUIDELINES 11.4 Look for a summary document that was either sent out, posted on site or discussed at a meeting or presentation (other forms of communication can be accepted but must be explained in comment section). 11.5 Company should look at the number and type of injuries occurring year after year, as well as audit scores. If no audit has been previously completed, you can compare injury record to current WorkSafeBC statistics. 11. RECORDS AND STATISTICS YES NO 11.4 Are health and safety records and statistics shared with all employees? SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 11.5 Does the company compare health and safety performance year to year? BCCSA Small COR Audit Document - Version 1.0 29

Contract systems GUIDELINES 12.1 Verify that there is a policy which addresses a plan or system developed in-conjunction with other employers to ensure worksite health and safety. 12.2 Check documentation to ensure that there is a clear record of Prime/Sub Prime designation from prior/current worksite and the responsibilities associated. 12.3 Check documentation to see if your company received a site specific orientation when working as a sub contractor. If you are a prime contractor, look for documentation showing that you have administered a site specific orientation. 12. CONTRACT SYSTEMS YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 12.1 Is there written policy addressing contract systems? 12.2 Do records indicate that written responsibilities for Prime Contractors and/or Sub Contractors were developed? 12.3 Are site specific orientations completed? BCCSA Small COR Audit Document - Version 1.0 30

Part 3: Injury Management/Return to Work OPTIONAL The Injury Management/Return to Work (RTW) element is an optional element. Successful completion of this element qualifies companies to be submitted for an Injury Management/RTW Certificate of Recognition and an additional 5% rebate from WorkSafeBC. NOTE: This section can only be filled out if you have received a total equal too or greater than 80% in the above 12 elements BCCSA Small COR Audit Document - Version 1.0 31

return to work GUIDELINES 13.1 Check training records to determine if Injury Management was covered. 13.2 Verify that there is a signed and dated policy outlining management commitment. Policy date must not be more than a year old. 13.3 Check injury records to see if initial and/or continual contact occurred. If no injuries have taken place, check documentation to ensure that a procedure is in place for contact with the injured employee (i.e. initial phone call). 13.4 Review documentation (training records, safety meeting minutes, safety committee minutes, etc.) to determine if policies and procedures have been communicated to all employees. 13. injury management YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 13.1 Have you provided any training or orientation for Injury Management? 13.2 Is there a policy outlining management commitment and is it signed and currently dated? 13.3 Are there records indicating that initial/continual contact with an injured employee has taken place? 13.4 Have Injury Management/RTW policies and procedures been effectively communicated to all workers, supervisors, and managers? BCCSA Small COR Audit Document - Version 1.0 32

return to work cont d GUIDELINES 13.5 Confirm proof of a written Injury Management/RTW Program. 13.6 Check to see that modified/light duties are highlighted. 13.7 Review training documentation to determine if Injury Management/RTW Program information is provided in a new employee orientation. 13.8 Check documentation to determine if a process is in place to make medical practitioners aware of the Injury Management/ RTW program (ability of an employer to provide alternate or modified duties). 13. injury management YES NO SUPPORTING DOCUMENTATION (WHERE IT S LOCATED) 13.5 Is there a written Injury Management/RTW Program? 13.6 Is there light duty/modified work available? 13.7 Are new employees provided with information on the Injury Management/RTW Program at a new employee orientation? 13.8 Are medical practitioners advised of the company s Injury Management/RTW initiatives? BCCSA Small COR Audit Document - Version 1.0 33

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Audit Score Sheet HEALTH & SAFETY PROGRAM VERIFICATION AUDIT SCORE Minimum Standard = 80% overall score (40 marks) and 50% each section Actual Score x 100 = % Possible Score Standard Achieved: Yes No INJURY MANAGEMENT/RETURN TO WORK AUDIT SCORE Minimum Standard = 80% overall score (7 marks) Actual Score x 100 = % Possible Score Standard Achieved: Yes No BCCSA Small COR Audit Document - Version 1.0 35

AUDITOR EXECUTIVE SUMMARY REPORT The Auditor Executive Summary Report is the SINGLE MOST important part of the audit process. The report must be detailed enough for the company to address the shortfalls in their program. Step 1 Paragraph 1 Thank the organization for their effort and help during the audit. Identify the individual who assisted during the audit. Step 2 Paragraph 2 Supply a brief description of the company being audited, including scope of work, size and any other relevant information that may have affected the audit findings. If any variances have been made on the number of sites visited and interviews conducted should be explained in detail in this paragraph as well. Step 3 Paragraph 3 State the positives that were found during the audit. (I.e. worker involvement in hazard assessments, development of safe work practices etc.) Step 4 Body Summarize the audit by element, listing existing strengths and recommendations for improvement for each. Ex. Element 1: Corporate Health and Safety Policy management and workers are aware of their responsibilities. Supervisors need more information on their roles and responsibilities. Recommend the BCCSA supervisors course. Step 5 Recommend development, implementation, and follow-up on the suggestions that have been made in the form of an action plan. Step 6 Thank the company for allowing you to present the audit, and that if they focus on the recommended changes, their program can be more effective at protecting its workers. NOTE: The Auditor Executive Summary must be completed, dated and signed. BCCSA Small COR Audit Document - Version 1.0 36

AUDITOR EXECUTIVE SUMMARY REPORT Company Name: End Date of Audit: Page of Auditor Signature: Date: BCCSA Small COR Audit Document - Version 1.0 37

CORRECTIVE ACTION PLAN The Audit Corrective Action Plan is to be completed by the company being audited (auditee) after the auditor has presented the completed audit results. The Audit Corrective Action Plan describes the steps that will be taken to address deficiencies identified in the audit report. While it is the responsibility of the company (auditee) to complete the report, the auditor may be able to provide ideas on appropriate recommendations for corrective actions at the time the audit findings are presented to the company. The Audit Corrective Action Plan will: prioritize identified deficiencies and recommendations from the audit identify corrective action(s)/improvements required assign responsibility establish implementation/completion dates, and Documented corrective action plans demonstrate a level of DUE DILIGENCE only when the corrective actions have been effectively implemented. NOTE: THE CORRECTIVE ACTION PLAN MUST BE COMPLETED, DATED AND SIGNED IN INK BY OWNER OR SENIOR MAN- AGER AND SUBMITTED WITH THE AUDIT DOCUMENT Documented corrective action plans demonstrate a level of DUE DILIGENCE only when the recommendations have been effectively implemented. NOTE: It is not an expectation or a requirement that the company have all recommendations that are listed on their action plan implemented prior to submitting the plan for review. Target dates for completing each of the recommendations in the action plan should be realistic. Timeframes for carrying out each of the corrective actions will undoubtedly vary; some recommendations may be implemented relatively quickly, while others will require a longer period of time to implement effectively. It is important to keep a copy of the Audit Corrective Action Plan to ensure follow up and documentation on the status of each of the recommendations is completed. BCCSA Small COR Audit Document - Version 1.0 38

CORRECTIVE ACTION PLAN Company Name: End Date of Audit: Page of AUDIT ITEM Corrective Action REQUIRED PRIORITY assigned to TARGET COMPLETION DATE DATE COMPLETED reviewed by Signature (Owner or Senior Manager) Date BCCSA Small COR Audit Document - Version 1.0 39

CODE OF CONDUCT & ETHICS Auditors must strive to maintain a high level of professional conduct at all times and that audits are performed consistently. Auditors shall: exercise honesty, objectivity, and diligence in the performance of their duties. refrain from entering into any activity that may be construed as a conflict of interest, an which may impair their ability to conduct their duties objectively. only undertake work activity that they are competent and qualified to carry out. protect the confidentiality of information obtained during the audit and ensure the anonymity of all individuals contacted during the audit process. maintain the highest standards of honesty and integrity during the application of audits. not knowingly engage in acts or activities which are discreditable to the profession of auditing in the occupational health and safety field. I,, have read and understand the Auditor Code of Conduct & Ethics as stated above. I agree with the above requirements and will strive to adhere to these rules. As an auditor, I realize that any breach of the Code of Conduct & Ethics may result in a formal review and/or loss of certification. Signature: Date: BCCSA Small COR Audit Document - Version 1.0 40

Submission checklist Before the audit is submitted please ensure the following is completed and enclosed: 1. Health and Safety manual 2. Corrective action plan 3. Executive summary 4. Supporting documentation that was used or referenced 5. Comment provided for each question in the audit 6. Completed audit document Corrective Action Plan - Fill out a corrective action plan for each answer that results in a No response. The action plan must state the problem, how it will be corrected, assign responsibility to an individual, and have a projected completion date. Executive Summary - Describe strengths and weaknesses with the current program, and try to have a few strengths and weakness for each section of the checklist. Also, describe the safety activities that took place throughout the year. Supporting documentation that was used or referenced - The Auditor may want to include supporting documentation not contained in the health and safety manual (i.e. training records, health and safety orientation records, inspection reports, etc.) BCCSA Small COR Audit Document - Version 1.0 41

#400, 625 Agnes Street, New Westminster, BC, V3M 5Y4 t: 604.636.3675 / tf: 1.877.860.3675 / f: 604.636.3676 / e: info@bccsa.ca www.bccsa.ca