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WHSMP08: DOCUMENT CONTROL AND RECORDS MANAGEMENT PROCEDURE

Section 1 - Purpose and Scope

(1) The purpose of this procedure is to ensure the management of the creation, review, access, and distribution of workplace health and safety (WHS) documents at Southern Cross University (SCU) are appropriately managed and controlled. 

(2) The purpose of this procedure is to ensure Southern Cross University’s management, employees, contractors, students, visitors and others are aware of the management of the creation, review, access, and distribution of workplace health and safety (WHS) documents in the workplace, management strategies and to provide advice on appropriate controls. 

(3) This is to ensure that the documents are approved before use, stored consistently to allow ease of access and that only the most up-to-date documents are available, remain legible, and readily identifiable, traceable, and prevent the unintended use of obsolete documents.  

(4) This document also encompasses the control, storage, protection, retrieval and disposal of records so that they can be accessed and retained as required for business operations, and to satisfy legal requirements. 

(5) All employees, students and others including both independent contractors and contractors under SCU control are to be made aware of and follow this procedure. 

(6) This Procedure applies to all SCU Work Units and sites. The procedure aligns with WHS legislation in the relevant jurisdictions SCU operates in. 

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Section 2 - Definitions  

Document 
A document is information in the form of a policy, procedure, guideline, form or other template that explains the steps for meeting a specific requirement or to record information that then becomes a completed record.   
Records 
A record is a document stating results achieved or providing evidence of activities performed.   
Records can be used to provide evidence of verification and corrective action. 
SCU 
Southern Cross University 
Workplace 
Any place where work is carried out for a business or undertaking and includes any place where a worker goes, or is likely to be, while at work. 
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Section 3 - General Principles 

Document Creation, Review and Approval 

Document Register 

(7) Each document template will be recorded in WHSMP08 – FOR – 01 Document Control Register. 

(8) The register will be used to record the following information: 

  1. Document number. 
  2. Document type. 
  3. Document name. 
  4. Function. 
  5. Version number. 
  6. Status. 
  7. Development / review / approval. 
  8. Date approved. 

(9) The Work Unit is responsible for managing the maintenance of the document register for their area in the event a new document is created, amended, or archived.  

Document Creation 

(10) If a new WHSMS document is to be created: 

  1. Seek the Director, Workplace Relations approval of new WHSMS documents before commencing development.  
  2. Check the SCU document register first to ensure it does not already exist. 
  3. Apply the appropriate document numbering in the footer of the document to be consistent with other WHSMS documents. 
  4. The document owner of the new document is responsible for ensuring completeness, revision control, workability, and legal accuracy of the document. 
  5. If the new document replaces an existing document, ensure the previous document is appropriately archived.  

Document Numbering 

(11) A document reference will include the following properties separated by a dash (-) without spaces. 

  1. University  
  2. Discipline 
  3. Work Unit 
  4. Document Type 
  5. Number (sequential order) 
Organisation Code 
Discipline Code 
Work Unit 
Document Code 
Examples 
SCU 
Southern Cross University 
 
SCU 
WHS 
Workplace Health & Safety 
FoH 
Faculty of Health 
POL  
Policy  
WHS Policy 
SCU-WHS-GRP-POL-1.0 
 
Procedure 
SCU-WHS-GRP-PRO-1.0 Working at Heights  
 
Template 
SCU-WHS-GRP-TEM 1.0 Task Hazard Analysis  
 
 
PRO 
Procedure 
GUI 
Guideline 
TEM 
Template 
FOR 
Form 
 
 

Document Control, Change and Revision 

Revision numbering 

(12) Revision numbers for drafts and released documents will be noted within the document footers and will have the following format: 

  1. Ver 0.1 – the document is in ‘draft’. 
  2. Ver 1.0 – the document has been ‘approved’ for use. 
  3. Ver 1.1 – the document is currently ‘under review’ 
  4. Ver 2.0 – the document has been ‘reissued’ 

Document Change 

(13) Any employee may request changes to be made to the WHSMS. The requester shall first initiate a discussion with the WHS Manager on the proposed changes to be made. Once changes are agreed, the document owner shall proceed to revise the document and obtain necessary approvals.  

(14) The revised document shall be identified with a new revision number and details of changes made shall be recorded in the SCU Document Register. The WHS Manager shall be responsible for updating the Policy and Procedure Library to the latest revised documents. 

Document Control 

(15) Only documents available on the Policy and Procedure Library are authorised and controlled. Any printed document is automatically uncontrolled. Archived and previous versions will be removed from the relevant online folder and placed into the archived documents folder until no longer required. Superseded documents shall be removed from the online system or properly identified and segregated to prevent unintended use.  

Document Review 

(16) The document review process shall be in accordance with the following table.  

Document Type 
Review Period 
Policy 
Annually 
Overview manual 
2 years 
Procedures and Guidelines 
2 years 

Document Storage and Distribution 

(17) All documents from the Document Register are to be stored electronically on the SCU Policy and Procedure Library.  

(18) Documents shall be accessible to all relevant internal parties through individual user system access.  

(19) Internally documents can be circulated via: 

  1. Notification via the Policy and Procedure Library. 
  2. Email notification 
  3. External distribution to other parties shall be at the written approval from the SCU WHS Manager. 
  4. Documents of External Origin 
  5. External documents which are necessary for planning and/or operation must be stored in the online system.  
  6. The custodian shall monitor for updates and ensure that the latest version of the external origin documents is maintained on the online system in a suitable location, readily available for reference.  
  7. The custodian shall communicate and circulate new and/or updated external documents and their online location to all relevant internal parties for their information. 

Record Management 

Identification Retention and Storage 

(20) Records shall be legible, readily identifiable, and retrievable. 

(21) All electronic safety records produced by SCU during operations are to be saved online and named according to the source document they originate from and include the date of development (format – YYYYMMDD). e.g. 20240218 Workplace Inspection – First Aid Equipment 20240315 Ride on Lawn-mower Competency Assessment – Bill Smith.

(22) The WHS Manager is responsible for developing RiskWare mapping of where records required to be kept are to be stored.  

(23) Hard copy records required to be kept are to be stored and retained in such a way that they are readily retrievable, and in facilities that provide a suitable environment to prevent damage, deterioration, or loss.  

(24) Records that have expired during the retention period are disposed of only by the WHS Manager or authorised delegates.  

Electronic Storage and Security of Data 

(25) Shared drives are backed up regularly and recoverable from offsite storage accordingly. For recovery contact Technology Services.  

Archiving Storage and Disposal 

(26) WHS Manager shall periodically undertake record archiving.  

Retrieval of Archived Records 

(27) Any current employee can request the retrieval of archived records. A valid reason for the retrieval of records shall be provided as part of the request.  

(28) The requester shall request the retrieval or records in writing to the WHS Manager.  

(29) Approval from the WHS Manager shall be sought and granted in writing before the release of records.   

(30) Requests from previous employees or external parties shall be: 

  1. requested via the WHS Manager,  
  2. reviewed by SCU Legal where required, and 
  3. approved by the Director, Workplace Relations before records being released.  
  4. Where approved by the Director, Workplace Relations, and SCU Legal as appropriate, they will determine the method of release.  

Disposal or archiving of records 

(31) When the destruction date is due, the WHS Manager shall arrange the destruction of records, and where needed seek advice from the Director, Workplace Relations. 

(32) The WHS Manager shall ensure the records are destroyed as authorised, and by a method that maintains the confidentially of any sensitive records with a register maintained online of the destroyed records.  

Archiving of WHS Records 

(33) The below table outlines the archiving timeframes for WHS records.  

Record Type 
Retention Duration 
WHSMS documents – policies, procedures, guidelines and associated documents  
10 years from closure of workplace or removal or mobile plant from site. 
Employee Records – where asbestos, lead exposure or other health surveillance is required. 
Life of Company. No Limitation 
Note: Health records are to be kept confidential at all times. 
Employee Records – where there have been injury claims or are potential claims 
Life of Company. No Limitation 
Until the claim has been settled and finalised 

Disposal of WHS Records 

(34) Disposal of workplace health and safety-related records shall be carried out following the applicable legal and other requirements.  

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Section 4 - Roles and Responsibilities

University Council  

(35) The SCU Council has the following WHS responsibilities: 

  1. Demonstrate commitment to WHS and set examples for employees. 
  2. Ensure regulatory compliance with standards and procedures. 
  3. Maintain WHS management systems meeting policy, legal, and regulatory requirements. 
  4. Review WHS risks periodically and consider implications in decisions. 
  5. Oversight of the development and alignment WHS strategy with university objectives. 
  6. Agree on and monitor WHS objectives, targets, and performance. 
  7. Provide adequate WHS training and resources for roles. 
  8. Review and learn from WHS incidents and trends and ensure corrective actions. 
  9. Ensure  crisis management processes for incidents are implemented. 
  10. Cooperate with regulators and WHS Manager on legislative requirements. 
  11. Monitor and report WHS performance, maintain relevant records, and track progress against objectives. 

Operational Responsibilities 

(36) The SCU Vice Chancellor has the following WHS responsibilities: 

  1. Foster a positive WHS culture with continuous improvement and leading by example. 
  2. Appoint competent resources for WHS roles based on risk profile, including an advisor for WHS duties. 
  3. Allocate resources for WHS systems and training for direct reports. 
  4. Manage key stakeholder and regulatory relationships. 
  5. Comply with WHS legislative requirements and collaborate with authorities. 
  6. Ensure compliance with WHS policy and legal requirements is monitored through plans and reviews. 
  7. Take actions to achieve WHS objectives and address deficiencies. 
  8. Implement disciplinary measures for WHS breaches as needed. 

Vice Presidents/Pro/Deputy Vice-Chancellor 

(37) Vice Presidents/Pro/Deputy Vice Chancellors have the following WHS responsibilities: 

  1. Be aware of, monitor and control critical hazards and controls applicable to their work unit 
  2. Ensure compliance with WHS policies, procedures by persons involved in their work unit’s undertaking. 
  3. Incorporate WHS risks in the Enterprise risk register and apply controls. 
  4. Provide oversight of Work Unit WHS performance, reporting, and sharing lessons from incidents. 
  5. Appoint and allocate appropriate WHS resources for risk management and training. 
  6. Foster a positive WHS culture, promote continuous improvement, and lead by example. 
  7. Cooperate with Regulators/Authorities and WHS to meet legislative requirements. 
  8. Review safety performance, discuss with management, and take corrective actions as needed, including disciplinary measures for WHS breaches. 

Head of Work Unit 

(38) The Head of the Work Unit has the following WHS responsibilities: 

  1. Ensure compliance with WHS policies, procedures, and controls. 
  2. Ensure WHS compliance, communication, and risk management. 
  3. Provide oversight for Work Unit WHS performance. 
  4. Promote a positive WHS culture and competency. 
  5. Manage WHS incidents and reporting. 
  6. Obtain and follow WHS professional advice. 
  7. Coordinate with regulators and WHS teams. 
  8. Conduct audit and assurance activities and ensure action on findings. 
  9. Engage with stakeholders on WHS matters. 
  10. Report accidents and incidents promptly. 
  11. Enforce disciplinary measures for WHS breaches. 

Managers and Supervisors 

(39) Managers and Supervisors have the following WHS responsibilities: 

  1. Ensure compliance with WHS policies, procedures, and controls. 
  2. Ensure access to competent WHS advice and training. 
  3. Provide resources and approval for safe activities. 
  4. Cooperate with regulators, WHS Manager, and Partners. 
  5. Monitor and act on regulatory visits and incidents. 
  6. Conduct assurance activities. 
  7. Engage stakeholders on safety matters as needed. 
  8. Report and record all WHS incidents promptly. 
  9. Review Work Unit WHS performance regularly. 
  10. Enforce disciplinary measures for WHS breaches. 

Employees 

(40) All employees have the following WHS responsibilities: 

  1. Complete required WHS training and stay updated. 
  2. Prioritise health and safety for oneself and others. 
  3. Ensure compliance with WHS policies, procedures, and control  
  4. Report WHS concerns promptly to relevant personnel. 
  5. Cooperate with SCU on WHS matters. 
  6. Understand and adhere to WHS procedures and risk assessments. 
  7. Notify relevant management of unsafe conditions or practices. 
  8. Work within established safety controls and systems. 
  9. Support WHS objectives and targets. 
  10. Use equipment only with proper training. 
  11. Wear issued PPE correctly. 
  12. Request additional WHS training if needed. 
  13. Follow instructions from authorities and supervisors. 
  14. Report accidents, defects, or hazards promptly. 
  15. Participate in audits and reviews as required. 
  16. To cease work if there is a reasonable concern of a serious risk or an immediate or imminent hazard poses serious risk to health and safety 
  17. To inform supervisor if work is ceased. 

WHS Team 

WHS Manager 

(41) The WHS Manager has the following responsibilities: 

  1. Develop and lead the University's health and safety strategy. 
  2. Implement and maintain WHS policies, procedures, and controls. 
  3. Provide oversight and reporting on WHS performance. 
  4. Develop and maintain WHS management systems. 
  5. Ensure compliance with legal and regulatory WHS requirements. 
  6. Assess and manage WHS risks effectively. 
  7. Promote visible leadership in WHS. 
  8. Communicate progress against WHS plans and objectives. 
  9. Ensure adequate WHS resources and training. 
  10. Provide WHS advice to management and maintain relationships with regulators. 
  11. Investigate and report accidents/incidents, sharing lessons learned. 
  12. Develop and monitor a WHS compliance assurance program. 
  13. Support SCU in new research, sites, and acquisitions. 
  14. Maintain accurate WHS data and reporting. 
  15. Regularly review and address WHS incidents and performance. 

WHS Business Partners  

(42) WHS Business Partners have the following responsibilities: 

  1. Assist work units with the application of procedures.  
  2. Support understanding and compliance with SCU standards and regulations. 
  3. Assist in WHS risk assessments and controls implementation. 
  4. Actively promote WHS culture and plans. 
  5. Maintain skills and stay updated on legal requirements. 
  6. Advise on WHS training needs. 
  7. Cooperate with regulators and WHS Manager on legal requirements. 
  8. Report incidents and support investigations. 
  9. Support WHS inspections, audits, and corrective actions. 
  10. Ensure accurate WHS data in RiskWare and meet reporting requirements. 
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Section 5 - Records of Documentation  

(43) All relevant documentation will be recorded and kept in accordance with WHS Legislation and other legislative obligations including:  

  1. Consultation 
  2. Training regarding this to procedure 
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Section 6 - Revision and approval history 

(44) This procedure will be reviewed as per nominated review dates or because of other events, such as: 

  1. Internal and external audit outcomes. 
  2. Legislative changes. 
  3. Outcomes from management reviews. 
  4. Incidents. 
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Section 7 - References 

Work Health and Safety Act 2011 
Work Health and Safety Regulation in applicable jurisdiction that SCU operates  
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Section 8 - Related Documents 

WHSMP08 - FOR - 01 - Document Control Register