DUE: NOVEMBER 27, 2017
Safety Group Sponsor Name:
Firm Name:
Date (dd/mmm/yyyy):
WSIB Account #:
WSIB Firm #:
Completed by:
Telephone:
Job Title:
Email:
2017 SGAP Requirements
(1) Standard for HSMS Audit Program
written and implemented
(2) Auditor Training
Refer to pages 4 & 8 of 2017 Employer
Requirements for qualification standard
Program Requirements
1.
2.
3.
4.
5.
6.
Standard written
Current date
Roles & Responsibilities
Auditor qualifications
Audit Plan
Continual Improvement Plan
(CIP) process
1. Specify Auditor training
qualifications in the written
standard
2. Train or verify Auditor(s)
meet the specific
qualifications of the written
standard.
(3) Review 2016 or most recent HSMS
Audit and Continual Improvement
Plan (CIP)
1st year SGAP participants review
their 2016, or most recent, Safety
Group Evaluation, and Making
Improvements steps.
1. Previous HSMS Audit and
CIP reviewed by trained
Auditor
2. Verified all non-conformities
on CIP
3. Verified CIP implementation
progressing as planned
4. Reviewed CIP action items
for effectiveness.
2017 Advantage Program
Year End Report/Checklist
Completed – Yes or No
Required
supporting
documentation
attached
Written standard meeting all program
requirements completed and
implemented:
Copy of 2017
Written HSMS Audit
Standard attached:
☐Yes
☐No
Auditor training completed or verified
prior to commencement of audit:
☐Yes
☐No
Auditor formally reviewed most
recent HSMS Audit and CIP as
outlined on page 4 and 5 of 2017
Employer Requirements:
☐Yes
☐No
☐Yes
☐No
Copy of Training
Record(s) attached:
☐Yes
☐No
Copy of Review
included in Audit
Report and is
attached:
☐Yes
☐No
Optional selfscore
(4) Complete 2017 HSMS Audit
2017 HSMS Audit selected:
______________________
(5) Written 2017 HSMS Audit Continual
Improvement Plan (CIP)
1. Completed an approved
HSMS Audit by qualified
Auditor
2. HSMS Audit included a RTW
Section that was audited to
the WSIB WR policies
3. All supporting audit evidence
listed for each audit
requirement
4. Audit includes a stated
finding for each requirement
5. Auditor signed/dated
completed audit
6. Documented evidence, with
date of Sr. Management
reviewing and accepting
audit findings.
Approved HSMS Audit completed,
meeting all program requirements:
1. All audit non-conformities
are addressed on 2017 CIP
with detailed action points to
resolution, assigned
responsibilities and timelines
established
2. CIP includes action points
started in 2017; and all other
non-conformities started
within 6 months of audit
completion
3. Non-conformities prioritized
4. Documented evidence of
CIP being reviewed, dated
and approved by Senior
Management
5. Documented evidence of
quarterly reviews of CIP by
Senior Management.
Written CIP meeting all program
requirements completed:
Senior Management Signature /Title / Date:
☐Yes
☐No
☐Yes
☐No
Copy of complete
HSMS Audit
attached:
☐Yes
☐No
Copy of 2017
Continual
Improvement Plan
attached:
☐Yes
☐No
Joint Health & Safety Representative (Optional):
I hereby certify that the information given on this form is correct and complete.
Note - Supporting documentation is not required to be submitted with this form. Firms selected for a validation audit will be
required to submit the required supporting documentation. These firms will have 2 weeks from the date of being notified of their
selection for a validation audit to submit all supporting documentation to their Safety Group Sponsor.