enform health and safety program … introduction to the cor policy and procedure manual –...

Table of Contents Approved: November 4, 2013 of 4

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

ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE:

Table of Contents

Action Plan


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


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


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 3.11.1: Safety Survey Quality Assurance Forms

Appendix 3.11.3: Safety Survey Audit Tool

Appendix 3.13.1: PASE Form (AB)

Appendix 3.13.2: PASE Form (AB & BC)

Appendix 6.10.1: COR Amendment Form

Appendix 8.1.1: H & S Program Development Course Content

1.1 Introduction to the COR Policy and Procedure Manual – Approved: March 11, 2013 Page 1 of 2

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 www.enformconnect.ca.

Questions about specific policies should be directed to [email protected].

Policy

1.1.1 Provincial Standards that Direct Enform Policy

1.1.1.1 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-002-1.1, December 14,

2006).

Joint Industry Committee: Framework of Standards for Health and

Safety Program Audits (JIC-002-2.2, March 29, 2007).

Joint Industry Committee: A Guide to the Framework of Standards

for Health and Safety Audits (JIC-002-2.3, June 27, 2007).

Joint Industry Committee: Framework of Standards for

Certification and Quality Assurance (JIC-002-3.2, June 27, 2007).

1.1.2 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

ENFORM HEALTH AND SAFETY CERTIFICATIONS PROGRAM POLICY & PROCEDURE:

1.1 Introduction to the COR Policy and Procedure Manual

mailto:[email protected]

http://www.worksafebc.com/insurance/partners_program/assets/standards_guidelines.pdf

http://www.worksafesask.ca/JIC-Certification

1.1 Introduction to the COR Policy and Procedure Manual – Approved: March 11, 2013 Page 2 of 2

Use of Elements outside the audit standard

1.1.3 Policy and Procedure manual approval and review process:

1.1.3.1 The review process will occur when new or revised standards are

communicated from the governing bodies.

1.1.3.2 The review process can also occur when clarification from staff is

requested or operational changes occur.

1.1.3.3 The policy is drafted and reviewed, approved and signed by Enform

management.

Procedure

1.1.4 General Information

1.1.4.1 The policies in this manual indicate the rules Enform applies when

interpreting and making decisions on issues.

1.1.4.2 The policy manual is provided to support the management of the COR

program in ensuring decisions and interpretations are met in a consistent

manner.

1.1.4.3 The table of contents outlines how this manual is organized.

1.1.4.4 All new or revised policies are developed to reflect all three provincial

jurisdictions.

1.1.4.5 Policies are approved by the Manager, Safety Audits and Certifications.

1.1.4.6 For situations or issues not covered in this manual or situations that

require special consideration, consultation with management for further

direction is required.

1.1.4.7 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

1.2 Content and Layout – March 16, 2013 Page 1 of 1

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 [email protected].

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

1.2.1 General Information

1.2.1.1 The table of contents outlines how this manual is organized.

1.2.1.2 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




1.2 Content and Layout


1.4 Acronyms – Approved: June 12, 2013 Page 1 of 3

List of Acronyms

AB Alberta

AHS Alberta Human Services

API Application Programming Interface

ARS Audit Registration System

ASME American Society of Mechanical Engineers

BC British Columbia

BCRSP Board of Canadian Registered Safety Professionals

CAGC Canadian Association of Geophysical Contractors

CAODC Canadian Association of Oil-well Drilling Contractors

CAPP Canadian Association of Petroleum Producers

CAR Corrective Action Report

CEO Chief Executive Officer

CEPA Canadian Energy Pipeline Association

CHSC Canadian Health and Safety Consultant

CHSMSA Health and Safety Management System Auditor

CMIS/WITS Compliance Management Information System/Wellsite Information Transfer Specification

CoE Code of Ethics

COR Certificate of Recognition

CORRS Certificate of Recognition Registration System

CP Certifying Partner


1.4 Acronyms

1.4 Acronyms Approved: June 12, 2013 Page 2 of 3

CRSP Canadian Registered Safety Professional

CSA Canadian Standards Association

CSO Construction Safety Officer

CSP Certified Safety Professional

DIO Documentation, Interview & Observation

DIR Disabling Injury Rate

e.g. For example

EIIPP Employer Injury & Illness Prevention Program

H&S Health and Safety

H2S Hydrogen Sulfide

HR Human Resources

IM/RTW Injury Management/Return to Work

IMS Institute of Mathematical Statistics

IQAS International Qualifications Assessment Service

IRP Industry Recommended Practice

ISO International Organization for Standardization

LAN Local Area Network

LTCR Lost Time Claim Rate

MECOR Medium Employer Certificate of Recognition

MOU Memorandum of Understanding

MSDS Material Safety Data Sheets

n/a Not Applicable

OHS Occupational Health and Safety

OJT On the Job Training

ORR Outline of Roles and Responsibilities

OSAR On-Site Audit Review

PA Partnerships Administrator

1.4 Acronyms Approved: June 12, 2013 Page 3 of 3

PASE Partnerships Audit Standard Equivalency

PC Partnerships Consultant

PEAT Potential Error Adjustment Template

PIR Partners in Injury Reduction

PPE Personal Protective Equipment

PRF Personal Reference Form

PSAC Petroleum Services Association of Canada

PST Petroleum Safety Training

QA Quality Assurance

SA&C Safety Audits and Certifications

SECOR Small Employer Certificate of Recognition

SEPAC Small Explorers & Producers Association of Canada

SK Saskatchewan

SMART Specific, Measurable, Attainable, Relevant & Timely goals

TDG Transportation of Dangerous Goods

WCB Workers’ Compensation Board

WHMIS Workplace Hazardous Materials Information System

WTD Weighted

1.5 Glossary of Terms – Approved: June 12, 2013 Page 1 of 5

Glossary

Action Plan 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.

Administrative Audit 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.

Audit 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

Audit Protocol A technical specification that guides and directs the performance of

an audit as well as the reporting structure and scoring.

Audit Report 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.

Auditor An individual certified to conduct health and safety audits.

Auditor Notes Notes prepared by the auditor during the audit that explain the

rationale used for determining the appropriate scoring.

Baseline Audit 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

1.5 Glossary of Terms Approved: June 12, 2013 Page 2 of 5

Boilerplated Notes Notes that are copies from notes prepared for previous employers or

audit reports, which many or may not have been altered.

Certification Audit 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.

Certifying Partner

(CP)

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.

Certified Auditor An auditor trained and certified by Enform.

Compliance Adherence to standards, regulations and other Enform requirements.

Corporate Auditor 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.

Corrective Action

Report

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.

Certificate of

Recognition (COR)

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.

Corrections The required revisions of the submitted audit.


Documentation 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.

Documentation

Review

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.

Employee Anyone who works for an organization (e.g., senior managers,

managers, supervisors, and workers).

Employer Term used to represent the complete scope of an organization; the

legal entity for whom employees work.

External Auditor An auditor trained by Enform to conduct audits for companies at which

they are hired.

Group Audit 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.

Governing Body Any provincial agency or regulatory body that serves as a partner in

the COR Program.

Health and Safety

Management System

is a systematic approach to managing safety, including the necessary

organisational structures, accountabilities, policies and procedures

Injury Management/

Return to Work

A program to facilitate injured workers to stay at work or return to

productive and safe duties as soon as physically possible after a work-

related incident.

Industry

Classification

Employers are assigned an industry based on the business they

conduct rather than by their employees' occupations.

Internal Auditor An auditor trained by Enform to perform audits for the company that

they work for.

Interview 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.

Lead Auditor The head of the auditor team who has overall responsibility for

organizing the audit team and carrying out the audit.


Large Employer For the purposes of the COR program, any employer with 11 or more

employees.

Limited Scope Audit An audit that is conducted only on deficient areas of an employer’s

health and safety management system.

Maintenance Audit A formal health and safety evaluation conducted by a certified auditor

for an employer to maintain their COR status between formal re-

certifications.

Medium Employer

Certificate of

Recognition

(MECOR)

This process is designed for growing SECOR certified companies and

new companies to the COR program with 11-19 employees. Over the

course of a three year cycle, employers transition from a SECOR to a

COR based certification.

Observation Part of a health and safety audit designed to allow an auditor to

observe and verify specific conditions at a work site.

Partnerships Audit

Standard

Equivalency (PASE)

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.

PASE Auditor 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.

PASE Report 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.

Policy The documented principles by which an organization is guided in its

management of affairs.

OSAR (On-Site Audit

Review)

An independent evaluation of the field work of a certified external

auditor.

Qualification Audit A formal health and safety evaluation conducted by an auditor

candidate pursuing auditor certification.

Quality Assurance A set of review activities intended to ensure that the completed audit

satisfies Enform’s audit standards requirements in a systematic,

reliable fashion.

Roll Up Audit 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.

Sample A portion, piece, or segment that is representative of the whole.


Representative

Sampling

A sample that accurately reflects the whole company and/or is of a

sufficient quantity to reasonable and accurately assesses the whole.

Six-Month COR 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").

Small Employer

Certificate of

Recognition

(SECOR)

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.

Small Employer For the purposes of the COR program, any employer with 10 or fewer

employees.

Student Auditor An individual who has completed the classroom training required to

conduct a student certification audit.

Template Notes 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.

Verification Audit An independent review of key areas of an employer’s health and safety

management system to validate that COR certification is justified.

Worker An employee supervised by a manager or supervisor/foreman.

Work Site A location where a worker is, or is likely to be engaged in any

occupation.

Work Site Sampling A sample of sites where workers perform work that accurately reflects

the work the company does.

of 6

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 www.enform.ca.

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.

http://www.enform.ca/

Safety Audits and Certifications: Outline of Roles and Responsibilities January 2013

Page 2 of 6

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

www.enform.ca.

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 email to Enform at

[email protected] 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.

http://www.enform.ca/



Page 3 of 6

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 email to Enform at [email protected]

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 4 of 6

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 5 of 6

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 45 days for on-site information gathering activities, calculated from the first day of on-

site activities.

o 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.

o 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.

o 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.

o Completing on-site audit activities by December 31st 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 6 of 6

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 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

o Submitting the student qualification audit within six months from the last day of the

Enform Certified Health and Safety Auditor Training Program.

o 45 days for on-site information gathering activities, calculated from the first day of on-

site activities.

o 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.

o 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.

o 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.

o Completing on-site audit activities by December 31st 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.

3.1 Overview: COR Audit – April 12, 2013 Page 1 of 1

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 [email protected] or

1-800-667-5557 option 3.


3.1 Overview: COR Audit


3.2 Audit Registration – Approved: June 10, 2013 Page 1 of 3

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

3.2.1 The auditor is responsible for the following in regards to audit registrations:

3.2.1.1 Register all audits with Enform prior to starting the audit.

3.2.1.2 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 For certification/recertification audits the current Enform Petroleum Industry

External Auditor list posted on the Enform website is to be used.

o 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.

o 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


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 For student only qualification audits, the timeframe is 6 months from the last day

of the Certified Health and Safety Auditor course.

o 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 Delaying the audit so minimum sampling requirements can be met (on site

activities must be complete prior to December 31st of the calendar year).

o Discuss alternate interview persons or sites to reach minimum sampling.

o 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.


Enform will:

Perform a QA review on the submitted audit registration to check for the following:

o Auditor credentials.

o Company information.

o WCB account validation.

o Audit type.

o Member/non member status.

o 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



3.3 Certification Audit – Approved: March 15, 2012 Page 1 of 3

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

3.3.1 To qualify for a certification audit, an employer must:

3.3.1.1 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.

3.3.1.2 Have active work sites available to audit.

Employers that cannot meet this requirement may consider the option of a

Six Month COR.

3.3.2 The auditor must:

3.3.2.1 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.

3.3.2.2 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.

3.3.2.3 Register the certification audit with Enform prior to the audit start date.


3.3 Certification Audit


3.3.2.4 Complete all on site data gathering activities within 45 days.

3.3.2.5 Submit a completed audit report to Enform within 45 days from the last day of

on site data gathering activities.

3.3.2.6 Address any deficiencies and required corrections arising from the audit QA

review within 30 days

3.3.2.7 Provide the employer with the final version of the audit report after it has

successfully completed Enform’s audit QA review.

3.3.3 The certification audit must:

3.3.3.1 Be conducted using the current Enform audit protocol.

3.3.3.2 Maintain the audit scope set out in the audit registration process.

3.3.3.3 Follow standards for minimum and representative sampling for interviews and

number of worksites reviewed.

3.3.3.4 Be subjected to an audit QA review by Enform whether or not it achieves the

minimum score required for COR certification.

3.3.3.5 Be retained by Enform until the employer’s subsequent maintenance audit or

certification audit is received.

3.3.4 For the employer to achieve COR certification, the audit must:

3.3.4.1 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).

3.3.4.2 Successfully pass an audit QA review by Enform.

3.3.5 Enform shall be responsible to:

3.3.5.1 Verify that auditors are fully certified at the time of audit registration.

3.3.5.2 Provide a timely audit QA review on all certification audits.

3.3.5.3 Inform the relevant governing bodies of successful COR certification audits.

3.3.5.4 Provide notification to employers when the audit QA review is complete.

Procedure

The employer:

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.


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


3.4 Maintenance Audit – Approved: March 28, 2012 Page 1 of 4

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

3.4.1 Employers are required to complete a COR maintenance audit in the two subsequent

calendar years after successfully completing a COR certification audit.

3.4.2 Enform shall inform employers of the requirement to perform maintenance audits

following a successful COR certification audit and on an annual basis.

3.4.3 An employer may also choose to renew their COR certification early by conducting a

certification audit in a maintenance year.

3.4.4 Maintenance audits must be conducted on active work sites.

3.4.4.1 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


3.4.4.2 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.

3.4.4.3 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.

3.4.5 The maintenance audit must cover the same scope of operations as the original

certification audit.

3.4.5.1 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.

3.4.5.2 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)

3.4.6 Maintenance audits must be completed by:

3.4.6.1 A certified external auditor, or

3.4.6.2 A certified internal auditor for the employer seeking the Maintenance Audit, or

3.4.6.3 An eligible student auditor that has successfully completed the Enform auditor

training programming and is seeking to complete an audit for auditor

certification purposes.

3.4.7 The auditor must:

3.4.7.1 Register the maintenance audit with Enform prior to the audit start date.

3.4.7.2 Complete all on site data gathering activities within 45 days.

3.4.7.3 Submit a completed audit report to Enform within 45 days from the last day of

onsite data gathering activities.

3.4.7.4 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.

3.4.7.5 Provide the employer with the final version of the audit report.

3.4.8 The maintenance audit must:

3.4.8.1 Be conducted using the current Enform audit protocol.

3.4.8.2 As much as reasonably possible, maintain the audit scope set out in the audit


3.4.8.3 Follow standards for minimum and representative sampling for interviews and

number of worksites included in the audit.

3.4.8.4 Successfully pass the Enform audit QA review.

3.4.8.5 Have onsite audit activity completed before the end of the calendar year

(December 31).


3.4.8.6 Where required by governing bodies, be scheduled so that maintenance audits

are at least 6 months apart.

3.4.9 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).

3.4.10 Enform will retain the employer’s maintenance audit on file until the Employer’s

subsequent maintenance or certification audit is received and approved.

3.4.11 If an Employer does not meet their maintenance requirement, Enform will cancel their

COR.

3.4.11.1 Enform will contact the employer to advise them that their COR is no longer

valid.

3.4.11.2 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


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.


Enform:

Receives and approves the audit registration request.

o Enform provides feedback on any audit plans it receives as part of the audit


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


3.5 SECOR Audit Overview – Approved: April 12, 2013 Page 1 of 1


engaging in achieving SECOR certification with Enform. Eligibility requirements to participate are

outlined as well as registration requirements for the assessor, auditor and employer.


1-800-667-5557 option 3.


3.5 Overview: SECOR Assessment


3.6 SECOR Assessment Conducted by a SECOR Assessor – Revised: March 13, 2013 Page 1 of 4

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

3.6.1 Small employers who are eligible for the Enform SECOR certification must:

3.6.1.1 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.

3.6.1.2 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 one day SECOR Refresher 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.

HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE:

3.6 SECOR Assessment Conducted by a SECOR Assessor

3.6 SECOR Assessment Conducted by a SECOR Assessor – Revised March 13, 2013 Page 2 of 4

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.

3.6.1.3 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).

3.6.2 The SECOR assessment must:

3.6.2.1 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.


3.6.2.2 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.

3.6.2.3 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.

3.6.2.4 Pass Enform’s audit QA review (see 3.30 SECOR Audit Quality Assurance

Review).

3.6.3 A SECOR assessment for certification must produce a minimum overall score of 80%

with 50% or greater in each element.

3.6.3.1 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.

3.6.4 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.

3.6.5 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.


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



3.9 Overview: Maintenance Options – Approved: April 13, 2013 Page 1 of 1


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.


1-800-667-5557 option 3.


3.9 Overview: Maintenance Options


3.10 Action Plan – Approved: March 26, 2012 Page 1 of 1

This policy has been updated. Please go to the Options to Auditing page on the

website to view the updated policy and access the updated forms.


3.10 Action Plan

http://www.enform.ca/cor/options-to-auditing.cfm

3.11 Safety Surveys – Approved: November 15, 2013 Page 1 of 5

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

3.11.1 For an employer to be considered for approval to perform a safety survey in lieu of a

maintenance audit, they must:

3.11.1.1 Have a current COR in good standing and have been active for a minimum of

four (4) consecutive years.

3.11.1.2 Have achieved 90% or higher overall audit score in their last recertification

audit.

3.11.1.3 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.

3.11.1.4 Safety surveys can only be used by employers in the regular COR program.

PASE, SECOR and MECOR holders cannot use this process.

3.11.2 Enform must pre-approve an employer for use of a safety survey as a maintenance

option.

3.11.3 The employer must use the Enform Safety Survey Audit Tool to conduct the safety

survey. (Appendix 3.11.3 Safety Survey Audit Tool).

3.11.3.1 The Safety Survey Audit Tool must meet the government requires as outlined in

Appendix 3.11.3 Safety Survey Audit Tool.


3.11 Safety Surveys


3.11.4 The safety survey process must be utilized over two (2) successive maintenance years.

3.11.4.1 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 3.11.3 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.

3.11.4.2 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.

3.11.5 Employer’s safety survey reports are archived by Enform for at least two years or until

their next recertification audit.

3.11.6 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:

3.11.6.1 The auditors was involved in all steps of the action plan process and signed off

on the final report.


3.11.6.2 The final action plan submission meets Enform’s quality assurance standards.

3.11.7 In year one, Enform will perform a QA Review (Appendix 3.11.1) of the submitted action

plan, safety survey summary reports, and sampling.

3.11.7.1 Completed information about the auditor and the audited organization must be

submitted with the survey deliverables.

3.11.7.2 The sampling breakdown must include the total number of respondents, listed

by level and department.

3.11.7.3 A summary of the survey results must identify employee perceptions of the

organization’s health and safety system.

3.11.7.4 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.

3.11.7.5 Deliverables must be complete, organized and professional in appearance.

3.11.8 In year two, Enform will perform a QA review on deliverables submitted by November 30.

3.11.8.1 The action plan must verify that a minimum of 80% of the action items have

been completed or are in progress.

3.11.8.2 Detailed and complete notes must be included to support the employer results

for each action item listed.

3.11.8.3 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.

3.11.8.4 Employers should avoid sending more documentation than what is strictly

required to verify completion of each action item.

3.11.8.5 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

3.11.3 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.


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 If 40% participation is not met a 15 day extension can be granted.

o 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.


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


3.12 Overview: Additional Audit Types – Approved: April 12, 2013 Page 1 of 1 Page 1 of 1


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.


1-800-667-5557 option 3.


3.12 Overview: Additional Audit Types


3.13 COR Audit Equivalency (PASE) Program – Approved: June 10, 2013 Page 1 of 4 Page 1 of 4

Background

Large employers with mature health and safety management systems may also have a well-

established 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:

3.13.1 Employers must submit a formal application (Appendix 3.13.1 and 3.13.2: PASE

Application and Gap Analysis) for participation in the PASE program.

3.13.1.1 The application to be submitted by March 31 of the year in which the

employer wishes to use the PASE program.

3.13.1.2 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.


3.13 COR Audit Equivalency (PASE) Program

3.13 COR Audit Equivalency (PASE) Program – Approved: June 10, 2013 Page 2 of 4

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.

A proposal for the transfer of audit scoring from the

employer’s audit instrument to Enform’s PASE gap analysis.

Gap Analysis phase:

3.13.2 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.

3.13.2.1 The employer has until May 31 to provide any additional gap analysis

information as a result of the gap analysis review.

3.13.2.2 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.

3.13.2.3 A gap analysis fee is applicable.

3.13.3 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.

3.13.4 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.

3.13.5 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.


Final PASE Report phase:

3.13.6 Audit scoring will be based on the previously approved proposal for the transfer of audit

scoring.

3.13.6.1 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.

3.13.6.2 Enform shall maintain a list of Enform certified auditors who are approved

to conduct PASE audits.

3.13.7 Where an employer conducts multiple audits in the course of their annual audit cycle, the

following standards apply to the audit cycle:

3.13.7.1 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.

3.13.7.2 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.

3.13.7.3 The cycle of work site sampling must adhere to the audit plan established

in the application process.

3.13.7.4 Any audits used in a given annual audit cycle may not be re-applied to a

subsequent audit cycle.

3.13.8 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.

3.13.9 The final PASE gap analysis report must include:

3.13.9.1 Auditor notes to justify the scoring for each question.

3.13.9.2 List of work sites covered, on-site information gathering dates for each,

and sampling details from each site.

3.13.10 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.

3.13.11 A minimum audit score of 80% overall and 50% for each element is required for the

employer to be eligible for COR certification.

3.13.12 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.

3.13.12.1 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.


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



3.15 Site Specific – Approved May 21, 2013 Page 1 of 2

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 3.15.1

and industry code, a site-specific audit may be conducted.

For sampling purposes, the audit must be representative of the work site audited, and 3.15.2

follow all governing body sampling requirements.

The auditor must fully describe the employer’s operations, including: 3.15.3

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, 3.15.4

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.


3.15 Site Specific

3.15 Site Specific – Approved May 21, 2013 Page 2 of 2

Once the audit has met all the governing body requirements, a site-specific COR 3.15.5

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 3.15.6

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 3.15.7

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 Indicates that the audit is site specific and provides a sampling plan (Appendix

M).

o Notifies Enform of any changes to the approved audit plan during the audit

process.

Enform will:

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).

o Track all employers performing site-specific audits using the iMIS system.

o Track whether the entire operation is eligible for a financial incentive.

o 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



3.19 Roll-Up Audit – Approved: June 13, 2013 Page 1 of 3

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

3.19.1 In order to be eligible for a roll-up audit, an employer must:

3.19.1.1 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.

3.19.1.2 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.

3.19.2 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:

3.19.2.1 The use of the Enform Audit Protocol.

3.19.2.2 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.

ENFORM HEALTH AND SAFETY PROGRAM CERTIFICATIONS POLICY & PROCEDURE 3.19 ROLL-UP AUDIT

3.19 Roll-Up Audit


3.19.2.3 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.

3.19.2.4 A time period of 45 days for information gathering.

3.19.2.5 Provision of recommendations for the specific unit audited.

3.19.3 Student auditors seeking auditor certification may participate in a roll-up audit under the

following conditions:

3.19.3.1 They must be under the supervision of a fully certified lead auditor.

3.19.3.2 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.

3.19.3.3 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.

3.19.4 The roll-up audit report must:

3.19.4.1 Be completed and submitted within 60 days of the last day on site for the last

audit conducted.

3.19.4.2 Only include individual audits conducted within the same calendar year as the

roll-up audit.

3.19.4.3 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.

3.19.4.4 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.

3.19.4.5 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.


3.19.5 Enform:

3.19.5.1 Must conduct a full audit QA review on the submitted roll-up audit report.

3.19.5.2 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



3.20 Team Audit – Approved: June 11, 2013 Page 1 of 2

Background

There are circumstances in which audits may be carried out by a team of auditors rather than an

individual auditor, such as:

The employer may be too large for one auditor to manage on their own.

Multiple certified auditors may need an opportunity to participate in an audit as a means

of maintaining their auditor status.

Student auditors may require an opportunity to participate in an audit for auditor

certification purposes, if acceptable to Enform.

Policy

3.20.1 Audits conducted for the purposes of attaining or maintaining a COR may be conducted

by a team of auditors. All members of an audit team conducting a COR-certification audit

must be certified auditors external to the employer and/or approved as corporate

auditors.

3.20.2 Student auditors external to the employer may participate in a certification audit only as

observers and as part of a mentoring process. Certified auditors internal to the employer

can participate as part of the audit team only if they are approved as corporate auditors.

3.20.3 All members of an audit team conducting an internal maintenance audit must be certified

auditors, unless Enform pre-approves an individual’s participation on an audit team for

auditor certification.

3.20.4 Where allowed by Enform, each student auditor taking part in a team audit for auditor

certification, must participate in all parts of the audit (documentation review, observation

tour, and interviews), submit their own results and report to Enform for audit review and

approval.

3.20.5 When audits are conducted by a team of auditors:

3.20.5.1 The lead auditor must be clearly identified, actively participate in the data

gathering activities, and be responsible for the audit results, quality of the

report, and report sign-off.

3.20.5.2 All other members of the audit team, along with their roles in the audit

process, must be identified in the audit report.

3.20.5.3 The audit report writer must be a certified auditor or student auditor (where

allowed), and have actively participated in the on-site information gathering as

a member of the audit team.

3.20.5.4 Individuals who assist the audit team with clerical functions (typing, formatting,

proof-reading, etc.) do not need to be identified inside the report.


3.20 Team Audit

3.20 Team Audit – Approved: June 11, 2013 Page 2 of 2

Procedure

The lead auditor:

Using the online audit registration system, indicate the appropriate audit type(s). For

example; team audit and/or student qualification audit.

The system guides the auditor to provide the following information:

o Identification of the lead auditor.

o Identification of all other auditors and their credentials.

o Identification of any student auditors that will use the audit as their qualification

audit or to fulfill Enform auditor certification maintenance requirements.

o Sampling plan to identify responsibilities (Appendix M: Sampling Plan).

Enform will:

Review the application for a team audit at the time of audit registration to ensure

compliance with the above policy, including:

o Confirm the credentials of all the included auditors and, where necessary,

student auditors.

o Flag any team audits that are being used by student auditors as an opportunity to

generate a qualification audit.

The qualification audit itself requires a separate audit registration and audit report

submission process.

When filing the audit report, the lead auditor:

Identifies the lead auditor.

Includes the credentials for each team audit participant.

Identifies the role and scope of work for each team audit participant.

o The lead auditor needs to confirm student auditors and auditors using a team

audit for auditor recertification were personally involved in documentation review,

work site observations, and interviews in the course of the team audit.

Identifies the audit report writer.

Upon receiving the team audit, in addition to a standard audit quality assurance (QA)

review, Enform will:

Ensure the additional required information in the audit report is included.

Return the audit to the designated audit report writer if there are any audit QA issues that

require addressing.

Document as required any auditors using the team audit for auditor certification

maintenance purposes.

Document any student auditor participating in the team audit and forwards confirmation

from the lead auditor that the student auditor did participate in documentation review,

work site observation, and interviews.

o This is then captured as a part of the audit QA review process for the separate

qualification audit.

Approval



3.23 Auditor Notes – Approved: March 27, 2013 Page 1 of 2

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

3.23.1 The auditor must write a note to justify the scoring of every audit question. These notes

must:

3.23.1.1 Reflect that the question guidelines have been followed.

3.23.1.2 Address each type of validation technique required to score the question.

3.23.1.3 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).

3.23.1.4 As appropriate and wherever possible, include company specific examples.

3.23.1.5 Be consistent with the notes and score awarded for other related questions.

3.23.2 Auditor notes must be original and specific to the audited employer’s health and safety

systems during the period of the current audit.

3.23.3 Auditor notes in the final audit report submitted to Enform and the employer should not

include the following:

3.23.3.1 Any direct reference to a specific employee.

3.23.3.2 Personal opinions of the auditor.


3.23 Auditor Notes

3.23 Auditor Notes – Approved: March 27, 2013 Page 2 of 2

3.23.3.3 Simple restatement of the audit question as the only justification for the score

awarded.

3.23.3.4 Contradictory information.

3.23.3.5 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



3.24 Audit Sampling – Approved: June 10, 2013 Page 1 of 4

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

3.24.1 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:

3.24.1.1 All departments.

3.24.1.2 All shifts.

3.24.1.3 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).

3.24.1.4 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).

3.24.1.5 A representative number of work sites (see 3.24.10).

3.24.1.6 Company history (if the company has been through a recent reorganization

or restructuring, include both “old” and “new” parts of the company).

3.24.2 The minimum number of interviews that must be conducted is determined by an

employer’s total number of employees.

3.24.2.1 The minimum number of interviews based on the total number of employees

can be found in Appendix F: Audit Work Site and Interview Sampling Tables.

3.24.3 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 3.24.1.


3.24 Audit Sampling


3.24.4 The choice of which employees to interview is to be selected by the auditor prior

to starting the audit.

3.24.5 All interviews must be carried out face-to-face by the auditor.

3.24.5.1 The use of interview questionnaires is not approved for Enform audits.

3.24.6 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).

3.24.6.1 The use of telephone interviews requires prior approval from Enform

and the rationale for these exceptions need to be noted in the audit

report.

3.24.6.2 Telephone interviews cannot be used as a substitute for a work site visit

required to meet representative work site sampling.

3.24.7 The auditor should provide an audit plan during audit registration that includes a

proposed interview sampling plan if auditing large and/or complex operations.

3.24.7.1 Enform will provide guidance to an auditor that submits an audit plan to

ensure interview requirements are fully understood in advance of the

audit.

3.24.8 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):

3.24.8.1 All activities under applicable WCB account(s) and industry code(s) or

classification unit(s).

3.24.8.2 Work site size differences.

3.24.8.3 The diversity of work conditions from one work site to another.

3.24.8.4 The location of the work sites.

3.24.8.5 The minimum number of work sites to be sampled as required by the

governing bodies.

3.24.8.6 For multi-jurisdictional audits, work site sampling must cover a sampling

of all provinces.

3.24.9 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.

3.24.9.1 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.


3.24.9.2 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.

3.24.9.3 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.

3.24.10 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.

3.24.11 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.

3.24.11.1 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.

3.24.12 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.

3.24.13 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.

3.24.14 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.

3.24.14.1 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.

3.24.15 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.

3.24.16 The auditor should contact Enform prior to registering an audit of a staffing company to

verify appropriate interview and work site sampling details.

3.24.17 Enform will confirm compliance with the interview and work site sampling standards

through the audit quality assurance (QA) review process.

3.24.17.1 An audit cannot pass Enform’s audit QA review process if it does not comply

with the interview and work site sampling standards.


Procedure

The auditor:

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 “Audit Work Site and Interview Sampling Tables” 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.

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



3.26 Extending Audit Scope to Out-of-Province Temporary Work Sites –

Approved: May 23, 2013 Page 1 of 4

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-of-

province work to maintain their COR certification.

Employers using this option are required to provide Enform with a report detailing their out-of-

province 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

3.26.1 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.

3.26.1.1 This option is not intended to eliminate including more than one province in

their audit for the sake of convenience.

3.26.2 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-of-

province temporary work sites in their audit scope. The application must:

3.26.2.1 Be submitted prior to registering or starting the audit.

3.26.2.2 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.

3.26.2.3 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.

3.26.2.4 Include a completed report of the employer’s health and safety performance

over the twelve months preceding the audit.


3.26 Extending Audit Scope to Out-of-Province Temporary Work Sites



3.26.3 Approval to include out-of-province temporary work sites in the audit scope is

valid only for the current audit year.

3.26.4 For approval to conduct an audit that includes out-of-province temporary work

sites, an employer must meet the following criteria:

3.26.4.1 The employer must maintain an office and operations in the province

they are seeking certification.

3.26.4.2 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.

3.26.4.3 Self-report to Enform on their health and safety performance over the

previous twelve months in their out-of-province operations.

3.26.4.4 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.

3.26.5 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:

3.26.5.1 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.

3.26.5.2 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.

3.26.6 Audits must meet the following criteria for interview and work site sampling:

3.26.6.1 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).

3.26.6.2 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.

3.26.6.3 Sampling must include a representative sample of fixed work sites,

including the administration or head office in the province where COR is

being sought.

3.26.6.4 Sampling must include a representative sample of temporary work sites

both in and out of the province where COR is being sought.



3.26.7 The application must include a report on the employer’s health and safety performance

that meets the following criteria:

3.26.7.1 The report must cover the twelve months preceding the audit date.

3.26.7.2 The report must include all operations in jurisdictions included in the audit.

3.26.7.3 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.

3.26.7.4 The out-of-province application must be signed by the president, a director, or a

senior office of the employer.

3.26.7.5 Enform must forward a copy of the out-of-province application to the governing

body.

3.26.8 Temporary work sites may include such activities as:

3.26.8.1 Oilfield drilling.

3.26.8.2 Oilfield servicing with mobile equipment.

3.26.8.3 Other operations which are temporary and/or utilize mobile equipment.

3.26.9 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.

3.26.10 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


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.



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



3.26 Out-of-Province COR – Approved: May 1, 2013 Page 1 of 3

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

3.27.1 To be eligible for a COR, an out of province employer must:

3.27.1.1 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)).

3.27.1.2 Successfully complete all applicable health and safety training requirements (if

applicable).

3.27.1.3 Use an Enform certified external auditor and the Enform COR audit protocol.

3.27.1.4 Comply with all applicable Enform audit standards.

3.27.1.5 Work site sampling requirements are based on out-of province operations.

3.27.2 Out-of-province employers are restricted to a one-year COR.


3.27 Out-of-Province COR


3.27.3 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:

3.27.3.1 The report must cover the twelve months preceding the audit date.

3.27.3.2 The report must include all operations in jurisdictions included in the audit.

3.27.3.3 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.

3.27.3.4 The out-of-province application must be signed by the president, a direction, or

a senior office of the employer.

3.27.3.5 Enform must forward a copy of the out-of-province application to the governing

bodies.

3.27.4 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.

3.27.5 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


3.27.6 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:

3.27.6.1 Are no longer considered out-of-province COR holders.

3.27.6.2 Must include the newly established location(s) within the scope of their next

scheduled audit.

3.27.6.3 May be required to perform a new certification audit if the newly established

operations differ significantly from the scope of their original certification audit.

3.27.7 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:

3.27.7.1 Meet the self-reporting requirements outlined above.


3.27.7.2 Establish and maintain a WCB account in the province in which they hold an

out-of-province COR.

3.27.7.3 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.

3.27.7.4 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.

Procedure

The Enform certified auditor:

Using the online registration system, registers the audit prior to the start of the audit.

Requests in writing via [email protected] 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




3.30 SECOR Assessment Quality Assurance Review – Approved: March 27, 2013 Page 1 of 4

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

3.30.1 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.

3.30.2 A standardized SECOR assessment QA review form shall be used to evaluate the quality

of the assessment report (see Appendix O: SECOR Assessment Quality Assurance (QA)

Review Form).

3.30.2.1 Where required, the SECOR assessment QA review forms have been

approved by the applicable governing bodies.

3.30.3 Upon receipt of a SECOR audit, Enform staff shall ensure the employer and the SECOR

assessor have met the Enform SECOR training requirements

3.30.4 An Enform audit reviewer shall use the appropriate SECOR assessment QA review form

to ensure:

3.30.4.1 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

email.

SECOR assessor name, phone number, and email.

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.

3.30.5 When performing an assessment QA review on a SECOR audit report completed by a

company SECOR assessor, the audit reviewer shall ensure all questions scored “yes” in

the audit have been sufficiently justified with adequate supporting information. This

includes confirming that:


3.30 SECOR Assessment Quality Assurance Review


3.30.5.1 Where sample documentation is required by the audit guidelines, adequate and

appropriate supporting documentation are attached to the assessment to verify

a “yes” response.

3.30.5.2 Overall documentation must verify the employer’s health and safety activities

over the previous twelve month period.

3.30.5.3 Where notes are required by the audit guidelines, sufficient quality and quantity

of assessor notes are provided to verify a “yes” response.

3.30.5.4 The information provided within a question and across all questions is not

contradictory.

3.30.5.5 The audit instrument and process have been applied and followed as per the

audit guidelines.

3.30.5.6 All “no” responses have been addressed by clear and relevant action items in

the SECOR action plan form.

3.30.6 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.

3.30.7 The audit score for a SECOR assessment completed by a company SECOR assessor

will be calculated by the Enform audit QA reviewer.

3.30.8 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:

3.30.8.1 SECOR assessors must return a corrected audit within 30 days of receiving

their audit QA review feedback asking for clarifications or corrections.

3.30.8.2 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.

3.30.8.3 Where deficiencies are not sufficiently addressed within this QA timeframe, the

QA standards have not been met and the audit will be rejected.

3.30.9 Any deficiencies in the SECOR audit must be captured in the action plan form.

3.30.9.1 Deficiencies identified by the QA reviewer that were not originally noted by the

SECOR assessor will be noted in the audit QA review feedback.

3.30.9.2 Employers are expected to revise their original action plans to account for any

additional deficient items identified by the QA reviewer.

3.30.9.3 Employers with deficient action plans will not be required to submit a revised

action plan to pass their audit QA review.

3.30.9.4 Employers may be asked to submit their previous year’s action plan to

demonstrate or confirm progress on action items.

3.30.10 Upon successful completion of the SECOR audit QA review process, Enform shall inform

the employer in writing.

3.30.11 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.


3.30.11.1 The employer will be informed of a decision by Enform to reject an audit report

that fails the Enform audit QA review process.

Procedure

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.

o A fresh assessment will need to be conducted if the employer wishes to achieve

certification, recertification or maintenance of their COR.


Approval



3.31 SECOR External Audit Quality Assurance Review – March 27, 2013 Page 1 of 4

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

3.31.1 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.

3.31.2 A standardized SECOR external audit QA review form shall be used to evaluate the

quality of the audit report (see Appendix O: SECOR External Audit Quality Assurance

(QA) Review Forms).

3.31.2.1 Where required, the SECOR audit QA review forms have been approved by the

applicable governing bodies.

3.31.3 Upon receipt of a SECOR audit, Enform staff shall ensure the employer has met the

Enform SECOR training requirements.

3.31.3.1 Enform staff ensures at the time of audit registration that external auditors are

qualified.

3.31.4 An Enform audit reviewer shall use the appropriate SECOR audit QA review form to

ensure:

3.31.4.1 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

email.

External auditor name, phone number, email 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.


3.31 SECOR External Audit Quality Assurance


3.31.5 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:

3.31.5.1 The notes reflect the correct validation method for the question (documentation,

interview, or observation).

3.31.5.2 The individual notes address all the documentation and informational

requirements stipulated by the audit guidelines for the individual questions.

3.31.5.3 The audit instrument and process have been applied and followed as per the

audit guidelines.

3.31.5.4 All “no” responses have been addressed by clear and relevant action items in

the SECOR action plan form.

3.31.5.5 The audit score provided by the external SECOR auditor has been correctly

calculated.

3.31.5.6 The auditor notes provided by the external SECOR auditor as scored by the QA

reviewer meet a minimum overall standard of 80%.

3.31.6 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:

3.31.6.1 External auditors must return a corrected audit within 30 days of receiving their

audit QA review feedback asking for clarifications or corrections.

3.31.6.2 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.

3.31.6.3 Where deficiencies are not sufficiently addressed within this QA timeframe, the

QA standards have not been met and the audit will be rejected.

3.31.7 Any deficiencies in the SECOR audit must be captured in the action plan form.

3.31.7.1 Deficiencies identified by the QA reviewer that were not originally noted by the

external auditor will be noted in the audit QA review feedback.

3.31.7.2 Employers are expected to revise their original action plans to account for any

additional deficient items identified by the QA reviewer.

3.31.7.3 Employers with deficient action plans will not be required to submit a revised

action plan to pass their audit QA review.

3.31.7.4 Employers may be asked to submit their previous year’s action plan to

demonstrate or confirm progress on action items.

3.31.8 Upon successful completion of the SECOR audit QA review process, Enform shall:

3.31.8.1 Inform the employer that they are to expect a final, approved version of the

audit report from their auditor.

3.31.8.2 Inform the auditor they are responsible to provide the employer with a final,

approved version of the audit.


3.31.9 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.

3.31.9.1 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 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.

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 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 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.


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 and the auditor 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



4.1 Overview: Auditor Qualifications – Approved: April 12, 2013 Page 1 of 1

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.


1-800-667-5557 option 3.


4.1 Overview: Auditor Qualifications


4.2 Auditor Certification – Approved: June 14, 2013 Page 1 of 4

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 Hold a certificate, diploma, or degree in Occupational Health and Safety and/or a

Canadian Registered Safety Professional (CRSP) or other equivalent safety

designation,

o 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,

o 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

4.2.1 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


been granted equivalency and will not be considered to have met the minimum

educational requirements to become an Enform external auditor.

4.2.2 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 http://employment.alberta.ca/cps/rde/xchg/hre/hs.xsl/4512.html

o The cost of the IQAS assessment is the responsibility of the external

auditor applicant

http://employment.alberta.ca/cps/rde/xchg/hre/hs.xsl/4512.html


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 Must be engaged in the OHS occupation for pay and livelihood

o 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


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 www.enformconnect.ca).

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



http://www.enform.ca/cms-assets/documents/70214-578106.auditor-agreement-nov-2011.pdf

4.3 Auditor Recertification – Revised: June 19, 2013 Page 1 of 2

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

4.3.1 Certified auditors must be recertified at least once every three years.

4.3.2 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.

4.3.3 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.

4.3.4 Auditors whose certification has been expired for six months or more are required to re-

apply 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.

4.3.5 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

4.3 Auditor Recertification – Revised: June 19, 2013 Page 2 of 2

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 The auditor scores less that 80% on the re-write of the Certified Health and

Safety Auditor exam.

o The auditor fails to re-write the Certified Health and Safety Auditor exam within

three months of taking the original exam.

o 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 Attend the one-day Certified Health and Safety Auditor Renewal course.

o If applicable, achieve a mark of 80% or higher on the revised auditor training

exam.

o Successfully completing a minimum of two audits or maintenance audit

options within the three year auditor certification period.

Approval



4.6 On Site Audit Review – March 8, 2016 Page 1 of 5

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

4.6.1 In order to verify the work of auditors conducting external audits, OSARs will be

conducted annually.

4.6.2 OSAR selection will be based on any of the following criteria:

4.6.2.1 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.

4.6.2.2 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.

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.


4.6 On-Site Audit Review


4.6.4 Outside of Alberta, the OSAR process is initiated and administered by Enform.

4.6.5 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).

4.6.6 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?

4.6.7 Employers whose audits are selected as a part of the OSAR sample are required to

participate in the process.

4.6.7.1 An employer’s COR will not be jeopardized by the OSAR results; though

employers may be required to work with Enform to correct any issues identified

with their health and safety management systems (see section 4.6.12).

4.6.7.2 Where OSA Reviewers identify areas for system improvement, they will provide

employers with feedback (see section 4.6.8.3).

4.6.7.3 If an employer’s audit is sampled as the result of a concern over the validity of a

specific auditor’s work, Enform reserves the right not to approve the audit until

the OSAR has been completed.

4.6.7.4 If an employer fails to cooperate with the OSAR process their COR may be

cancelled.

4.6.8 OSA reviewers must meet the following minimum criteria. OSA reviewers must:

4.6.8.1 Be certified Enform auditors.

4.6.8.2 Sign and abide by the Enform Audit Reviewer Code of Ethics (Appendix T) in

order to avoid any conflict of interest, and to ensure confidentiality of the

process.

4.6.8.3 Complete training on the OSAR process.

4.6.8.4 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.

4.6.9 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.

4.6.9.1 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.

4.6.9.2 On-site reviews will be completed using Enform’s OSAR template

(Appendix R).


4.6.9.3 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.

4.6.9.4 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.

Defer discussion of any serious concerns about the employer’s health and

safety management systems or the original audit to a follow up discussion

with Enform.

4.6.10 Following the OSAR, the OSA reviewers will:

4.6.10.1 Review the OSAR finding to the original audit for comparison.

Enform will provide the original audit report to the reviewer only after

completion on the OSAR visit.

4.6.10.2 Provide feedback to Enform or the governing body regarding any serious

concerns regarding substandard auditor performance or serious deficiencies in

an employer’s health and safety management systems that are not noted in the

original audit.

4.6.10.3 Complete the OSAR report and submit to Enform or the governing body within

14 days of the OSAR visit.

4.6.10.4 Destroy or delete all information collected during the OSAR including the

auditor’s report once confirmed that the completed OSAR report has been

received.

4.6.11 Enform will communicate the OSAR findings to the original auditor.

4.6.11.1 The name of the OSA reviewer will not be disclosed to the original auditor.

4.6.12 Where significant deficiencies are identified with the auditor’s performance/process, an

investigation will be initiated and the Enform Auditor Performance Management process

will apply.

4.6.12.1 Depending on the outcome of the investigation, the auditor may be prohibited

from conducting the next audit for the sampled employer.

4.6.13 In the event that the OSA reviewer identified significant deficiencies in the sampled

employers health and safety management system, Enform will work with the employer on

a plan to correct the identified issues in a timely manner.

Where the original audit is shown to be misleading, Enform and/or the governing

body may require a follow-up certification audit for the employer to maintain their

COR status.

4.6.14 Enform will provide the provincial governing bodies with the details of any follow-up

investigation/disciplinary actions that result from an OSAR. This includes action to make

required improvements to the employer’s COR-certified health and safety management

systems.


Procedure

In jurisdictions where a governing body administrates the OSAR process:

The governing body:

Selects, trains, and contracts OSA reviewers with feedback from Enform.

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.

Provides Enform with a copy of the OSAR for follow up purposes with the auditor and

employer as required.

Enform:

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.


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.

Performs the on-site review using Enform’s OSAR protocol.

Requests the original audit report from Enform immediately after completing on site

information gathering activities.

Provides the governing body with a completed OSAR report within 14 days of on-site

information gathering activities.

Approval

Juliet Goodwin, CRSP


4.8 Enform Employees as Auditors – Approved: March 11, 2013 Page 1 of 1

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




4.8 Enform Employees as Auditors

5.1 Standards for Audit Reviewers – Revised: March 11, 2013 Page 1 of 3

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.

Policy

5.1.1 Audit reviewers must have sufficient education, training and experience to competently

review audit reports and identify both strengths and deficiencies of the document and the

audit process.

5.1.2 The education and background experience required to be an Enform audit reviewer

differs depending on the types of audits being reviewed (SECOR, COR maintenance,

COR certification, etc.)

5.1.3 All staff and consultant audit reviewers are under the direction of a supervising

manager(s).

5.1.4 The supervising manager(s) of audit reviewers must:

5.1.4.1 Have a minimum of five years and a broad spectrum of occupational health and

safety experience.

5.1.4.2 Hold either:

A certificate, diploma, or degree in occupational health and safety or related

degree; or

A Canadian Registered Safety Professional (CRSP) designation (or

equivalent).

5.1.4.3 Be an Enform Certified Health and Safety Auditor.

5.1.4.4 Be trained by Enform as an audit reviewer.

5.1.4.5 Sign and remain in compliance with the Enform Audit Reviewer Code of Ethics.


5.1 Standards for Audit Reviewers


5.1.5 Staff completing COR certification audit reviews must:

5.1.5.1 Have a minimum of three years of occupational health and safety experience.



degree; or


equivalent).

5.1.5.3 Be an Enform Certified Health and Safety Auditor.



5.1.5.6 Have their work regularly reviewed by the supervising manager(s) of audit

reviewers.

5.1.6 Staff completing COR maintenance audit reviews must:

5.1.6.1 Have a minimum of one year of occupational health and safety experience.

5.1.6.2 Hold or be in the progress of working towards a certificate, diploma, or degree

in occupational health and safety or related degree.

5.1.6.3 Hold or be in the progress of working towards Enform Certified Health and

Safety Auditor certification.


5.1.6.5 During the training period, have their work reviewed by the Lead Audit Advisor.



reviewers.

5.1.7 Staff completing SECOR self assessment reviews must:

5.1.7.1 Hold or be in the progress of working towards a certificate, diploma, or degree

in occupational health and safety or related degree.

5.1.7.2 Complete Enform’s Safety Program Development course.

5.1.7.3 Be trained by Enform as a SECOR audit reviewer.

5.1.7.4 During the training period, have their work reviewed by the Lead Audit Advisor.


5.1.8 All consultant audit reviewers must:

5.1.8.1 Have a minimum of five years and a broad spectrum of occupational health and

safety experience.



degree; or


equivalent).


5.1.8.3 Be an Enform (or equivalent) Certified Health and Safety Auditor.

5.1.8.4 Have no enforced quality and/or ethic infractions under Enform’s Auditor

Performance Management standards.

5.1.8.5 Sign a contract with Enform for consulting services.




reviewers.

5.1.9 At least annually, Enform will review the performance of staff and consultant audit

reviewers.

5.1.10 A list of all potential audit reviewers will be maintained and made available to Enform

certified auditors.

5.1.10.1 An auditor with a real or perceived conflict of interest with an Enform audit

reviewer should contact Enform to discuss.

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



6.1 Overview: Certification (Process and Types) – Approved: April 12, 2013 Page 1 of 1

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.


1-800-667-5557 option 3.


6.1 Overview: Certification (Process and Types)


6.2 Three Year COR/SECOR – Approved: June 12, 2013 Page 1 of 5

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

6.2.1 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.

6.2.1.1 The last day of onsite audit activities serves as the certification date. The

COR/SECOR expiry date will be three years from this date.

6.2.2 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:

6.2.2.1 The employer has documented evidence of having had a health and safety

management system in place for at least one year.

6.2.2.2 The employer has active work sites available at the time of the audit.


6.2 Three-Year COR/SECOR


6.2.2.3 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).

6.2.2.4 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)

6.2.2.5 The audit is performed on an approved audit protocol and meets all the

established timelines and quality standards.

6.2.2.6 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.

6.2.2.7 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.

6.2.2.8 Employers who acquire new operations may require a new external audit to

certify the expanded scope of their business.

6.2.2.9 The audit achieves a score of 80% or higher overall and not less than 50% on

each audit element.

6.2.2.10 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).

6.2.3 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.

6.2.3.1 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.

6.2.3.2 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.


6.2.4 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.

6.2.4.1 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.

6.2.4.2 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.

6.2.4.3 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.

6.2.5 A SECOR certification is only available to an employer that has ten or fewer employees

across their entire scope of operations.

6.2.5.1 An employer may not apply for SECOR certification for a specific site or

industry if their overall operations exceed 10 employees.

6.2.6 An employer is not permitted to have a COR certificate and a SECOR certificate

simultaneously.

6.2.7 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.

6.2.7.1 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.

6.2.7.2 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.


6.2.8 Enform will forward all employer certificates received from governing bodies to

employers.

6.2.9 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.

6.2.10 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.

6.2.11 All companies achieving and maintaining a three-year COR/SECOR certification will be

listed on the Enform website.

6.2.11.1 The information included will be the employer’s legal and trade name, COR

type, and certification expiry date.

6.2.11.2 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.


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



6.10 Amendments to Certificates – Approved: June 3, 2013 Page 1 of 3

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 email 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:

acquisition of another company;

merger with another company;

addition of another division with a different industry;

addition of new facilities, or

management restructuring.

Policy

6.10.1 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 6.10.1 COR Amendment Form).

6.10.2 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 6.10.6).

6.10.3 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).

6.10.7.1 The new certificate will be re-issued only for the parts of the organization

that were included under the original certification audit.

6.10.7.2 The new certificate will retain the original expiry date.


6.10 Amendments to Certificates


6.10.4 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.

6.10.5 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 6.10.4);

new facilities; or

new division(s)

6.10.6 Notwithstanding section 6.10.5, 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:

6.10.7.1 The new owner commits to maintaining the existing health and safety

management system.

6.10.7.2 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.

6.10.7.3 The previous business operations continue essentially unchanged and

can be clearly distinguished from any other operations that may be

conducted by the new owner.

6.10.7.4 The scope of the new COR will be unchanged from that established by

the previous certification audit.

6.10.7.5 The new owner commits to meeting Enform’s COR maintenance

requirements established by the original certification audit.

6.10.7 Should an employer believe that their COR status is inaccurate, they may

request that Enform amend their COR.

6.10.7.1 COR amendments requested by an employer will be investigated jointly

by the governing bodies and Enform.

6.10.7.2 Should the employer’s concerns be substantiated, Enform will follow the

amendment process, as required.


Procedure

The employer will:

Provide the necessary documented evidence outlining/describing the change

using Appendix 6.10.1 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 email 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



6.13 Fraudulent Certificates – Approved: June 10, 2013 Page 1 of 3

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.

6.13.1 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.

6.13.1.1. All concerns reported must be in writing (letter or e-mail) and the

complainant’s name must be included.

6.13.1.2. If an individual wishes to raise their concerns anonymously, the caller will be

directed to Enform’s call centre or call centre email.

6.13.2 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.


6.13 Fraudulent Certificates


6.13.3 If it is determined that an employer has carried out any of the actions listed in

6.13.2, the following penalties may apply for a first occurrence.

6.13.3.1. 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.

6.13.3.2. The employer will be ineligible to apply for COR recertification for a

period of up to one year from the date of the decision.

6.13.3.3. All CPs and the appropriate WCB will be advised of the employer’s

name and the penalty imposed.

6.13.4 If it is determined that an employer has carried out any of the actions listed in

6.13.2 for a second time, the penalties listed under 6.13.3 will apply with the

following additional specification.

6.13.4.1. The employer will be ineligible to apply for recertification for a minimum

of two years.

6.13.5 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.

6.13.6 If the employer applies for certification before the end of their suspension period,

the application will be denied.

6.13.7 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 email to [email protected] outlining the concerns.

o Call the Enform COR call centre to report any concerns.



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



6.14 Employer Review – Approved: April 3, 2013 Page 1 of 2

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

6.14.1 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).

6.14.2 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.

6.14.3 If an employer fails to satisfactorily complete improvement activities such as an action

plan audit as required, the following processes may be followed.

6.14.3.1 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.

6.14.3.2 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.


6.14 Employer Review

6.14 Employer Review – Approved: April 3, 2013 Page 2 of 2

6.14.3.3 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.

6.14.3.4 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).

6.14.4 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.

6.14.5 Employers and/or Enform may appeal a COR cancellation as a result of a failed action

plan through an arbitration process.

6.14.6 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.

6.14.3.1 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



7.1 Health and Safety Program Fee Structure – Approved: June 3, 2013 Page 1 of 2

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

7.1.1 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.

7.1.1.1 The below annual fees will be charged to member employers that fit into the

following criteria:

7.1.1.1 Member employers in Alberta and Saskatchewan that have an Enform-

assigned WCB industry code.

7.1.1.2 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.

7.1.1.3 A list of Enform-assigned WCB industry codes in Alberta and

Saskatchewan can be found in Appendix A.

Annual Member Fee

Audit Type Annual Fee

SECOR (1-10 employees) $150 +applicable taxes

COR (11+ employees) $250 +applicable taxes

PASE Gap Analysis Fee** $2500 +applicable taxes


7.1 Health and Safety Program Fee Structure

7.1 Health and Safety Program Fee Structure – Approved: June 3, 2013 Page 2 of 2

7.1.2 The following annual fees will be charged to non-member employers that fall into

the following criteria:

7.1.2.1 Non-member employers in Alberta and Saskatchewan that do not have

an Enform-assigned WCB industry code.

7.1.2.2 Any employers operating outside of Alberta, Saskatchewan, or British

Columbia.

Annual Non-Member Fee

Audit Type Annual Fee

SECOR (1-10 employees) $500 +applicable taxes

COR (11+ employees) $1000 +applicable taxes

PASE Gap Analysis Fee** $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



7.4 Retention of COR Records – Approved: March 25, 2013 Page 1 of 1

Background

Prior to the introduction of the governing body’s online systems for application of COR/SECORS,

Enform was required to maintain their own records regarding employers, auditors, audits and

audit maintenance. While the online systems are now the central database for many of these

records, other critical information is not recorded (e.g. employer training, auditor training and

certification, refresher training, etc.). Enform must retain these records to facilitate inquiries from

auditors and employers, to provide required data for quality assurance of auditors, or to answer

refund questions from the applicable governing body.

Policy

7.4.1 Enform must enter and maintain COR data in the online systems as required by the

governing body.

7.4.2 Enform must retain relevant employer and auditor records that are not recorded in the

online systems for a minimum period to include the current year plus three prior years.

This includes (but is not limited to) the following records:

Employer training records.

Auditor training and certification records.

Audit sampling plans and scope information.

Procedure

Enform will:

Retain COR-related employer and auditor records using the iMIS database system.

Enter and maintain COR data in the online system as part of the audit process for the

governing bodies.

o This includes a process for a quarterly scheduled review of data entry

into the system to check for accuracy.

o The review will be documented in a spreadsheet similar to Appendix 7.1

to track corrections and follow up.

Approval




7.4 Retention of COR Records

Maintenance of COR/SECOR List – Approved: June 10, 3013 Page 1 of 1

Background

Enform will maintain a list of employers who have a COR/SECOR on the Enform website. The

list will be produced from current data and will be regularly updated by Enform.

Policy

7.6.1 The Enform COR/SECOR list will include all employers who hold a valid COR/SECOR as

recorded in the system on the date the list was created.

7.6.2 Designated Enform staff will be responsible for exporting the list from the current

database system, formatting into the acceptable format and forwarding the data to the

web master for posting.

7.6.3 For each COR/SECOR holder, the public list includes:

Legal name (as registered with the governing body);

COR type;

COR/SECOR expiry date; and

Province the COR/SECOR was issued under.

Procedure

Enform will:

On a quarterly basis access the report in iMIS under the generate reports link

and perform a quality assurance check of the results.

Ensure any data entry errors are corrected.

Once it is determined that the results are accurate, arrange for uploading the

report to the Enform website.

Approval




7.6 Maintenance of COR/SECOR List

7.7 PIR Program Requirements (AB) – Approved: June 3, 2013 Page 1 of 4

Background

The governing bodies and Enform will work together to ensure the timely and accurate year-end

processing of COR data through Certificate of Recognition Registry System (CORRS) to support

the calculation of PIR incentives.

Government of Alberta departments do not participate in the PIR incentive program.

With the introduction of the CORRS system, Enform began entering the required audit data into

the online CORRS system when audit reports are received and quality assurance reviews are

successfully completed.

The governing bodies conduct a quality assurance check on the data submitted by Enform. They

use this data to compile a list of companies eligible for PIR refunds.

While all parties make every effort to ensure audit data for the previous calendar year is entered

into the CORRS system by March 31, not all audits may be finalized by this date (as a result of

on-going audit corrections, limited scope audits, etc.). In some cases, Enform may still be

entering year-end audit results into CORRS as late as April or May of the following year.

Policy

7.7.1 To maintain eligibility for PIR refunds, employers must have met COR requirements on or

before December 31st of the measurement year.

7.7.1.1 Employers who hold a six-month COR on December 31 are not eligible for a

PIR refund for that calendar year unless they achieve a new three-year COR

during the next calendar year.

7.7.1.2 Employers whose six-month COR expires before December 31 will not be

eligible for a PIR refund for that calendar year unless they successfully

complete a recertification audit for a three-year COR before the end of the

year.

7.7.2 At the end of March following the measurement year, the governing body will send

Enform a report containing four lists. Enform must review and correct any errors in the

CORRS data for the listed employers within 7 days after receipt of the report.


7.7 PIR Program Requirements (AB)


7.7.2.1 List #1 identifies employers who hold valid CORs as of December 31

of the previous calendar year. For these employers, CORRS confirms

that the required supporting audits (or maintenance audit options)

were successfully conducted.

7.7.2.2 List #2 identifies employers who are listed in CORRS as having a

COR, but for whom the required supporting audits (or maintenance

audit options) were not recorded as completed for the previous

calendar year.

7.7.2.3 List #3 identifies employers who are registered in PIR, but who are

listed in CORRS as not having completed an audit or been issued a

COR during the previous calendar year.

7.7.2.4 List #4 identifies employers who are listed in CORRS as having

completed an audit in the previous calendar year, but for whom the

WCB is holding back PIR refunds.

7.7.3 By April 25 following the measurement year, Enform must record in CORRS any

audits (or maintenance audit options) that are still being processed from the

previous calendar year. These must be listed in CORRS as "incomplete." The

following information must be documented:

employer name

account number and industry code

audit type

audit start and completion dates

comment to explain why the audit is still in progress (e.g. auditor

making corrections, audit review pending, or limited scope audit

process not concluded)

7.7.4 At the end of April, the governing body will send a new report to Enform with four

updated lists

7.7.4.1 Enform must review and correct any errors in the CORRS data for the

listed employers within 7 days of receipt of the report.

7.7.5 Enform must cancel any CORs for which the required maintenance audits (or

maintenance audit options) have not yet been received for the previous calendar

year by April 30 of the current year.

7.7.6 In May, the governing body will request an exception report from WCB listing any

active CORS which still do not have the required maintenance audits (or

maintenance options) recorded in CORRS for the previous calendar year.

7.7.6.1 The governing body will advise the Enform of any CORs that are to be

cancelled and Enform will have 7 days to respond should there be a

valid reason why the COR should not be cancelled. The reasons must

be documented in CORRS.


7.7.6.2 After the 7 day notice period, the governing body will cancel any remaining

invalid CORs.

7.7.7 An employer who’s COR status was identified as not having the required maintenance

audit on the new report may still be eligible for a PIR refund for a prior year(s) under one

or more of the following circumstances:

7.7.7.1 The employer can successfully prove that an error has been made regarding

their COR status.

7.7.7.2 The employer successfully completes the approved limited scope audit

process.

7.7.7.3 The employer's final audit corrections successfully pass Enform’s audit

review.

7.7.7.4 The employer's audit (or maintenance audit option) could not be processed

until the WCB finalized account and/or industry changes for the year audited.

7.7.7.5 An employer holding a six-month COR on December 31 successfully

completes a new three-year COR during the next calendar year.

7.7.8 After April 25 of the current year, Enform must provide a written explanation to the

governing body for any changes requested to an employer's COR status for prior year(s).

This is not required for situations that were previously documented in CORRS as

"incomplete” with explanation.

Procedure

The governing body will:

Send Enform, at the end of March, a report to reconcile and resubmit.

After the reconciliation process, sends a Enform new report at the end of April to review

and correct any identified errors.

Send Enform, in May, an exception report prior to cancelling any remaining COR’s for

Enform to review and respond.

Enform will:

Pre-enter all audits submitted on an on-going basis into CORRS and provide comments

in CORRS stating the audit is under review.

After the review has been finalized access the pre-entered audit in CORRS, enter a new

comment to document that the review has passed and complete any other related fields

and submit the request.

Conduct periodic CORR’s entry quality assurance checks to ensure accuracy, identify

trends, and correct data entry errors.

Arrange for the review and verification of the initial PIR list. Make any updates to CORRS

with any changes, deletions or additions.


Arrange for the cancelation of any un-maintained CORs from the previous calendar year

by April 30 of the current year.

Communicate with any employers affected by a cancellation of their COR/SECOR.

Work with the Program Manager to identify and provide written explanation to the

governing body for prior year changes to an employer's COR status that are implemented

after April 25 of the current year.

Approval



7.8 WorkSafeBC Rebate Requirements – Approved: June 19, 2013 Page 1 of 2

Background

The COR program in BC recognizes and rewards the implementation of health and safety

management systems in occupational health and safety and return to work/injury management.

Because employers who implement such systems are exceeding the requirements of the

Occupational Health and Safety Regulation of BC, WorkSafeBC offers them a partial rebate of

assessments.

Financial incentives are paid to employers who achieve COR certification and who are in good

standing with WorkSafeBC.

Employers who earn the OHS COR can receive rebates of 10 percent of their

WorkSafeBC base assessment.

Employers who earn the RTW COR can receive additional rebates of 5 percent of their

WorkSafeBC base assessment.

These rebates are paid in the year following COR certification.

Policy

7.8.1 Enform serves as the employers’ main point of contact regarding all operational aspects

of the COR program, though it is not responsible for issuing WorkSafeBC rebates to

employers participating in the COR program.

7.8.2 Enform provides information to WorkSafeBC in a timely manner regarding the issuance of

COR certificates and the employer’s eligibility for rebates.

7.8.3 At the end of each calendar year, certifying partners will provide WorkSafeBC with a data

extraction of all employers who possess a valid COR certification through them.


7.8 WorkSafeBC Rebate Program Requirements

7.8 WorkSafeBC Rebate Requirements – Approved: June 19, 2013 Page 2 of 2

Procedure

At the end of the calendar year WSBC requests a list of all audits that have not been

entered into iCOR performed for the previous year to forecast the rebate amount.

Enform prepares the list to submit. The list is to include:

o Company Name (BC Legal Name and Trade Name)

o Audit Status

o Audit Type (Certification vs. Maintenance)

o Cert Type

o Certificate Sub Type (RTW)

o Audit Date

o WCB account number

o Classification Unit

The list should be reviewed for accuracy prior to sending to ensure all potential

employers eligible for a rebate are captured.

Enform responds in a timely manner to any requests for further information from WSBC.

In preparation for the spring rebate process, WSBC requests data clean up on any

records that appeared to have errors in the submission of the above mentioned list.

All previous year audits must be entered into iCOR by midnight April 4th to close off

business for the previous calendar year.

Unique cases of late audits can be entered using the Late Audit process.

Enform arranges to provide WSBC a list of employers who did not perform an audit in the

previous calendar year and require their certification to be cancelled.

Approval



7.9 Audit Protocol: Review and Approval – Approved: June 19, 2013 Page 1 of 2

Background

Audit instruments used to audit an employer health and safety management system for a COR

or SECOR must meet the minimum requirements and be approved by the governing bodies.

The governing bodies will conduct a review of all health and safety audit instruments and

quality assurance forms proposed for use by Enform. The review will be conducted to verify

that the proposed document(s) meet the requirements of the governing bodies standards.

A copy of approved audit instruments and quality assurance forms will be kept on file by the

governing bodies.

Policy

7.9.1 Enform audit instruments and quality assurance forms must be approved by the

governing bodies before they can be used for certification, recertification or maintenance

of CORs.

7.9.2 To be approved for use, audit instruments and quality assurance forms must meet the

governing bodies standard for content, scoring proportion, and use of required validation

techniques.

7.9.3 Approved audit instruments and quality assurance forms must be re-submitted for

approval if any revisions are made to the questions, the guidelines (when required to

meet the content criteria), the scoring allotments, or the assigned validation techniques.

7.9.4 Enform must revise their audit instruments and quality assurance forms and resubmit

them for approval when there are changes to the governing bodies’ audit standard.

7.9.5 Enform conducts an assessment of standards for Alberta, British Columbia and

Saskatchewan to ensure the protocol meets the requirements of all governing bodies.

7.9.5.1 The approval processes with those governing bodies vary; however in the end

the protocol must meet all governing bodies’ requirements.

7.9.6 Audit reviewers must use an approved quality assurance form to perform their audit

quality reviews (see Appendix N for the COR Audit Quality Assurance (QA) Review

forms).


7.9 Audit Protocol: Approval and Review

7.9 Audit Protocol: Review and Approval – Approved: June 19, 2013 Page 2 of 2

Procedure

Enform will:

Review the Enform audit instrument and quality assurance forms, when changes occur, to ensure they meet all of the content, scoring proportion and validation techniques requirements before sending them to the governing bodies for approval.

Ensure that audit instruments and quality assurance forms are not used for COR or SECOR purposes until they are approved by the governing bodies.

Communicate any changes that were made to the audit instruments and quality assurance forms to stakeholders.

Approval



7.14 Certifying Partner Review: Approved June 19, 2013 Page 1 of 3

Background

The governing bodies will conduct ongoing quality assurance audits on Enform.

Enform commits to maintaining administrative and quality assurance systems designed to meet

the governing bodies’ standards. To verify that standards are being met on an ongoing basis, the

governing bodies undertake regular audits of the work conducted by Enform, and offers

suggestions for improvement.

Where standards are not being met, Enform will correct the identified deficiencies in a timely

manner, and their follow-up must be verified by the governing bodies.

Policy

7.14.1 The formal review process begins with a formal letter to Enform, detailing

requirements for the audit.

7.14.2 Several different audit types, including, but not limited to, the following may be

conducted on Enform:

7.14.2.1 Verification audits designed to evaluate the quality of Enform’s audit

reviews by comparing a sample of audit reports and corresponding

reviews to the requirements of the governing bodies’ standard.

Any trends that are identified with the audit reports, Enform audit

reviews, Enform administrative processes, or any area where

Enform is not meeting the governing bodies standards are

identified in the audit report.

In some cases, specific audits or reviews will be identified for

further follow-up by Enform.

Verification audits may be conducted more frequently under the

following circumstances:

o The governing bodies identify significant deficiencies in Enform’ s process or violations of standards and must re-audit to confirm that recommendations have been implemented, or

o The governing bodies are made aware that incorrect or substandard practices are occurring in the period between Enform’s regularly scheduled reviews.


7.14 Certifying Partner Review


7.14.2.2 Audits of the online data entry systems for requesting Certificates of

Recognition may be conducted to verify that Enform is correctly

entering employer audit data into the system(s).

7.14.2.3 Full or partial reviews of Enform’s policy manual may be conducted

to verify that all appropriate policies and procedures are in place to

ensure standards are being met.

7.14.3 All governing bodies audit processes will result in a written report of findings at

the end of the audit process. These reports will include strengths, areas where

improvement is required in order to meet standards, and recommendations that

the Enform may want to consider.

7.14.4 The written report will be delivered to Enform during a post-audit meeting or

provided electronically.

7.14.5 A post-audit meeting or teleconference presents an opportunity for the Enform to

ask questions and respond to any issues identified. If a mutually agreed upon

recommendation for change to the draft report is made, the governing bodies will

make the change before the report is finalized.

7.14.6 In most cases, Enform will have 6 months to complete the action items identified

and submit the documents to the governing bodies for review.

7.14.7 If any action items remain outstanding after the original agreed-to timelines, the

governing bodies may meet with Enform to discuss the outstanding

recommendations and the plan to complete the actions.

Procedure

Enform will:

Receive notification that a CP audit will be occurring and confirms the dates.

Arrange meeting rooms and a place for the governing bodies to conduct the review.

Receive information from the governing bodies on the type of review, any identified

employers, date span of the audit and number of files to sample.

Prepare any necessary information or requests a recall of the identified audit (in SECOR

cases) from the employer to have available for the time of the audit.

Make staff available for interviews or to demonstrate the use of systems.

Responds to any deficiencies identified and create an action plan with target dates and

responsibilities identified to submit to the governing bodies for approval.


Provide updates to the governing bodies on the action plan items and their progress.

Confirm the completion of the action plan items.

Approval



8.1 Safety Program Development Course – Approved: June 19, 2013 Page 1 of 2

Background

To participate in the Certificate of Recognition (COR) program, each employer is responsible to

develop and implement their own health and safety management system. To assist employers

with this task, Enform has available a Safety Program Development course for participating

employers.

Policy

8.1.1 The Safety Program Development course offered by Enform covers the content criteria

as established by the governing bodies’ standards (Appendix 8.1.1 Health and Safety

Program Development Training Content).

8.1.2 The Safety Program Development course must be at least one day (minimum 7 hours) in

duration.

8.1.3 The course exams must measure candidates’ achievement of the course’s learning

objectives. Candidates must achieve a minimum of 80% on the exam to achieve

successful completion of the course.

8.1.4 Enform must keep records of candidates’ participation in the Safety Program

Development course and results achieved on the course exam.

8.1.5 Enform must require SECOR and MECOR users to complete their Safety Program

Development course in order to be eligible for certification.

8.1.6 Enform will perform a review of the course when changes occur to the audit instruments

and related or new governing bodies standards are introduced.

8.1.7 Enform course instructors must meet the qualifications (including the education and

experience) required for course instructors. These qualifications are:

8.1.7.1 Hold external/professional auditor certification from Enform or be an internal

auditor who meets the external certification prerequisites.

8.1.7.2 Hold either, a Canadian Registered Safety Professional (CRSP) designation or a

Certified Safety Professional (CSP) designation, or certificate, diploma, or degree

in Occupational Health and Safety.

8.1.7.3 Have experience in developing safety programs.

8.1.7.4 Successfully completed the Enform Instructional Skills Workshop (ISW).

8.1.7.5 Participate in the observation of one course, as a minimum, of a Safety Program

Development course given by Enform.


8.1 Safety Program Development Course

8.1 Safety Program Development Course – Approved: June 19, 2013 Page 2 of 2

8.1.7.6 Have instructed one Safety Program Development course under observation and

mentorship by an approved Enform instructor to verify competency.

8.1.8 Enform must evaluate the performance of the instructors at least annually.

Procedure

Enform will:

Review potential instructors to ensure they meet the requirements for instructor qualifications, training, and experience for the delivery of their Safety Program Development course.

Evaluate the performance of instructors on an annual basis, and provide feedback.

Include in the course an exam to measure whether candidates have understood course learning objectives.

Track candidates’ participation and successful completion of the course exam.

Notify the governing bodies when changes are made that affect the required content criteria of the Safety Program Development course, and submit the course material for verification.

Approval



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