OHSAS 18001 Audit Checklist

OHSMS Gap Analysis
Audittee:
Name of the Organization:
Facility Type: Auditor:
Location: Date:
Conducting the OHSMS Gap Analysis
Objectives
The OHSAS 18001 Standard is internationally recognized and used by industry and government organizations to enhance health and safety and operational
effectiveness, efficiency, and performance. Conducting an OHSMS gap analysis is a key step in developing and implementing an OHSAS 18001 OHSMS. The
objectives of this step include:
Assisting select Areas and facilities in determining how their health and safety management system compares to the 17 elements of the OHSAS 18001
OHSMS Standard, and
Improving OHSMS assessment tools and guidance to ensure practicality and compliance with health and safety requirements and other relevant
requirements.
Gap Analysis Background

The OHSMS gap analysis is a self-evaluation. A series of questions will help you compare your organizations current health and safety management practices
against the OHSAS 18001 Standard. This comparison provides a baseline assessment of your organization and helps you to identify current systems in place for
managing health and safety issues, including existing policies and procedures, roles and responsibilities, communication systems, training programs and others.
As you conduct the analysis, you will recognize strengths and weaknesses of your organizations present health and safety operations and determine the extent
to which your operations conform to the OHSAS 18001 OHSMS Standard.
Upon completion of the analysis, you should be able to identify which of the 17 OHSMS elements are already in place and which you need to develop or further
refine. Conducting the gap analysis will also help familiarize you with the OHSAS 18001 OHSMS Standard and the elements critical to developing,
implementing, checking, and improving the OHSMS on a continual basis.
Gap Analysis Questionnaire Description and Directions

The OHSMS Gap Analysis Questionnaire is a tool to help you conduct an OHSMS gap analysis assessment on your organization. When undertaking this
assessment, include people who have direct knowledge of as many health and safety and operational functions as possible. This is important so that several
employees gain exposure to the OHSMS process and also because each employee brings specific knowledge about health and safety practices from his or her
functional area.
The questionnaire first asks for basic organizational information and background information about the respondent who will be completing the survey such as
name, title, roles and responsibilities, and telephone number.
The bulk of the questionnaire addresses the OHSAS 18001 requirements. There are 17 short sections of questions that correspond to the 17 OHSMS elements.
The 17 sections fall under the five main OHSMS categories of health and safety policy; planning; implementation and operations; corrective action; and
management review. Each of the sections are labeled with the OHSMS element number so you can easily reference additional information about the 17
elements of the Standard.
There are three check boxes to the right of each of the questions on the Gap Analysis Questionnaire. After you respond to each question, place an "X" or a
check in the block that best describes the status of the component as it relates to your OHSMS. The status blocks in the gap analysis tool are represented as
follows:
Status
Not in place Partially in place In Place
0 1 2
A numerical rating measuring your organizations conformance to the OHSAS 18001 Standard is determined from the responses on this questionnaire. A
numerical rating is given for each component response as follows:
Not in place = 0 points Partially in place = 1 point In place = 2 points

The responses are totaled for the entire questionnaire resulting in your score. The highest score possible, 170, indicates all components of the 17 elements are
In place in your OHSMS (85 questions/components x 2 points for each component In place = 170 points). This baseline assessment enables you to focus on
continual improvement. In the electronic version of the OHSMS Gap Analysis Questionnaire provided with the OHSMS Toolkit, the second tab titled
"Summary Chart", contains a bar chart to give you a visual depiction of the degree to which you conform to the OHSAS 18001 OHSMS Standard. This chart
can be used in management presentations to show the progress of your OHSMS implementation.
Hints
1) List of Required Documentation and Records: The OHSAS 18001 OHSMS Standard requires physical (or electronic) evidence of certain documents and
records. This includes, for example, the organization's health and safety policy. There is a list at the end of this gap analysis questionnaire that highlights which
items require physical (or electronic) evidence in the form of documentation or records. The list is organized by each of the 17 elements in the Standard.
Elements of the OHSAS 18001 OHSMS Standard that require documentation are indicated in bold text in the gap analysis questionnaire for easy reference to
the requirements of the Standard.
2) List of Reference Material: The second part of the list at the end of this gap analysis questionnaire is a list of reference materials you may already possess
that could help you identify your current OHSMS status. This list is organized by each of the 17 elements of the Standard.
Question Category: health and safety policy

OHSMS Element 1: health and safety policy (OHSAS 18001, Paragraph 4.2)
Status
Finding / Corrective
Not in Partially in In Notes
place place place
Action
1. Has top management defined the organization's health and safety
x
policy?
2. Does your procedure (process) for the health and safety policy ensure
that the policy is appropriate to the nature, scale and health and safety
x
risks of its activities, products, and services that are within the defined
scope of your health and safety management system?
3. Does your health and safety policy within the defined scope of your
x
OHSMS commit to continual improvement and prevention of pollution?
4. Does your health and safety policy within the defined scope of your
OHSMS commit to complying with applicable health and safety legal x
requirements and other health and safety requirements?
5. Does your procedure (process) for the health and safety policy
provide a framework for setting and reviewing health and safety x
objectives and targets?
6. Does your procedure ensure that the health and safety policy is
documented, implemented, and maintained? x
7. Does your procedure (process) for the health and safety policy Policy awareness needs
x
communicate the policy to all persons working for or on behalf of the to be improved
8. Does your procedure (process) for the health and safety policy make Policy Needs to be made
the policy available to the public? available for public by
x
making it available on KG
website
Is the policy consistent with other corporate
x
policies affecting the business?
Status subtotals: 0 2 12
Status Total: 14 16 points available
Percentage complete: 88
Question Category: Planning
OHSMS Element 2: health and safety hazards (OHSAS 18001, Paragraph 4.3.1)
Status
Action
place place place
9. Does your procedure (process) for health and safety hazards address:
Identifying health and safety hazards of activities, products, and
services within the defined scope of the OHSMS that it can control and x
those which it can influence taking into account planned or new
developments, or new or modified activities, products and services?
10. Determining those hazards that have or can have intolerable risk on
x
the health and safety?
11. Maintaining a documented up-to-date list of all hazards including those HIRA register to be kept
x
that are significant? up-todate
12. Ensuring that significant health and safety hazards are considered in
developing, implementing and maintaining the OHSMS? x
Is there a risk assessment process to

determine significance or priority of identified x
health and safety hazards/risks?
OHSMS Element 3: Legal and Other Requirements (OHSAS 18001, Paragraph 4.3.2)
Status
place place place
Action
13. Does your procedure (process) for health and safety legal and other
health and safety requirements address:
x
Identifying applicable legal requirements related to your
organization's health and safety hazards?
Accessing applicable legal requirements related to your
x
organization's health and safety hazards?
The organization shall review at a regular frequency any changes to
x
legislation and keep this information up-to-date.
Communicating relevant information on legal and other requirements
to persons working under the control of the organization, and other x
relevant interested parties.
14. Does your procedure ensure that health and safety legal and other
health and safety requirements to which the organization subscribes
x
are considered in developing, implementing and maintaining your
organization's health and safety management system?
OHSMS Element 4: Objectives, Targets and Programme(s) (OHSAS 18001, Paragraph 4.3.3)
Status
Does your procedure (process) for Objectives, Targets and Programmes Not in Partially in In Notes
Action
address: place place place
15. Establishing and maintaining documented health and safety objectives

and targets at relevant functions and levels within the organization? x
16. Establishing measurable objectives and targets, where practicable, Reference to HSE Policy
that are consistent with the health and safety policy, including the statement needs to be
x
commitments to prevention of pollution, compliance with legal and given
other health and safety requirements and continual improvement?
17. The legal and other health and safety requirements, its significant Objective review
health and safety hazards, its technology options and its financial, frequency needs to be
operational and business requirements and the views of interested x defined
parties when establishing and reviewing objectives and targets?
18. Does your procedure (process) address establishing and maintaining Responsibilities needs to
programs for achieving your organization's objectives and targets, be defined
x
including designating responsibility for achieving objectives and
targets at relevant functions and levels of your organization?
19. Does your procedure (process) address establishing and maintaining Management programs
programs for achieving your organization's objectives and targets, needs to be prepared for
x
including the means and time-frame by which the objectives and achieving health and
targets are to be achieved? safety objectuves
Have specific health and safety improvement
objectives been communicated to all relevant
business units and employees, contractors and x
suppliers?
Confirm that the facility has established
compliance standards to be followed that are
x
reasonably capable of reducing the prospect of
criminal conduct.
Verify, where possible, that the facility has
taken steps to achieve compliance with its x
health and safety standards.
Verify that the facility has a program in place to
review the full range of capital projects,
maintenance modifications, process changes, x
and R&D initiatives to identify potentially
significant consequences.
Determine if these review are performed in a
timely manner, by appropriately trained
x
professionals and if a formal methodology is
employed.
Question Category: Implementation and Operation
OHSMS Element 5: Resources, roles, responsibility and authority (OHSAS 18001, Paragraph 4.4.1)
Status
Does your procedure (process) for resources, roles, responsibility and Not in Partially in In Notes
Action
authority address: place place place
20. Management ensuring the availability of resources (human resources
& specialized skills, internal infrastructure, technology and financial
x
resources) essential for the implementation and control of the health
and safety management system?
21. Defining, documenting and communicating the roles, responsibilities
x
and authorities to facilitate effective health and safety management?
22. Top management appointing a specific management representative
who, irrespective of other responsibilities, has defined responsibilities
and authority for:
x
Ensuring that an health and safety management system is
established, implemented, and maintained in accordance with the
requirements of OHSAS 18001?
Reporting on the performance of the health and safety management
system to top management for review and as the basis for x
improvement?
Verify if the roles and responsibilities cover:
Legal/regulatory tracking; Updating/reviewing
documentation control procedures; Training;
Policy and procedure development; Contractor
oversight; Follow-up to
x
inspections/audits/periodic reviews; Updating
the health and safety policy; Identifying health
and safety hazards/risks of on-site operations;
and, Responding to external requests for
information.
Verify that the roles are clearly
defined, documented, and
understood and that there are no
x
redundancies or gaps in the
coverage.
Interview staff from various operating

departments to confirm that health
and safety roles and responsibilities x
are clearly understood within the
facility.
OHSMS Element 6: Competence, training and awareness (OHSAS 18001, Paragraph 4.4.2)
Status
Does your procedure (process) for competence, training and awareness Not in Partially in In Notes
Action
address: place place place
23. Identifying training needs to ensure that any person(s) performing
tasks on the organization's behalf that have the potential to cause (a)
x
significant health and safety risk(s) identified by the organization is/are
competent on the basis of appropriate education, training, or
24. experience?
Identifying training needs associated with the organization's health and
safety hazards and its OHSMS? Providing training or taking other x
actions to meet these needs?
25. Making persons working for the organization or on its behalf aware of:
The importance of conformity with the health and safety policy and
x
procedures and with the requirements of the health and safety
management system?
The significant health and safety risks, actual or potential, of their
work and the health and safety benefits of improved personal x
performance?
Their roles and responsibilities in achieving conformity with the
health and safety policy and procedures and with the requirements of
x
the health and safety management system, including emergency
preparedness and response requirements?
The potential consequences of departure from specified operating
x
procedures?
The scope of training includes: Emergency
response and preparedness; The importance
of complying with established performance
criteria and the potential consequences of
departure from specified health and safety
operating procedures; Adequate detail to x
motivate personnel to prevent, detect, and
correct violations; and, The facility offers all
staff an opportunity to attend internal health
and safety training sessions.
Identify a sample of facility personnel who
perform tasks that can cause high health and x
safety risk.
Verify that these staff members have
received appropriate health and safety training x
relative to the job functions/tasks performed.
Confirm that the facility promotes health and
safety awareness through periodic
x
memoranda, use of bulletin boards, health and
safety newsletters, award programs, etc.
Confirm whether staff with health and safety
responsibilities have the relevant background,
x
training, and capabilities to effectively carry out
their responsibilities.
OHSMS Element 7: Communication (OHSAS 18001, Paragraph 4.4.3)

Status
Does your procedure (process) for Communication address: place place place
Action
26. Establishing and maintaining procedures for communication between
the various levels and functions of your organization with regard to
x
your organization's health and safety hazards and health and safety
management system?
HSE committee formation and meetings / HSE
improvement suggestion schemes / HSE
x
advices and other activities for consultation
and participation of employees
27. Establishing and maintaining procedures for receiving, documenting,
and responding to relevant consultation and participation from
interested parties with regard to your organization's health and safety x
hazards and health and safety management system?
28. The organization's decision on whether to communicate externally on

its significant health and safety hazards and the documentation of that x
decision?
If the decision is to communicate externally on its significant health
and safety hazards, does the organization have a method(s) for this x
external communication?
OHSMS Element 8: Documentation (OHSAS 18001, Paragraph 4.4.4)

Status
place place place
Action
29. Does your health and safety management system documentation
include:
x
An health and safety policy, objectives and targets for your
organization?
- a description of the scope of the health and safety management
x
system?
A description of the main elements of the health and safety
management system and their interaction and reference to related x
documents?
Documents and records required by the OHSAS 18001 Standard (at
x
minimum those bolded in this gap analysis tool)?
Documents and records the organization determined necessary to
ensure the effective planning, operation and control of processes that x
relate to its significant health and safety hazards?
OHSMS Element 9: Control of Documents (OHSAS 18001, Paragraph 4.4.5)

Status
place place place
Action
30. Does your document control procedure(s) address the need to control
documents required by the health and safety management system x
and by the International Standard?
31. Does your document control procedure(s) address the need to:
x
Approve documents before they are issued?
Review and update them as necessary, and re-approve them before
x
reissuing them?
Ensure changes and the current revision status of documents are
x
identified?
Ensure current documents are available at points of use? x
Ensure documents are legible and easily identifiable? x
Ensure that external documentation you deem necessary for the
planning and operation of the health and safety management system x
are identified and their distribution controlled?
Ensure obsolete documentation is not unintentionally used? x
Identify obsolete documentation if it needs to be retained for any
x
purpose?
Evaluate whether: There are systems in place
to ensure that all required reports are sent to
regulators in a timely fashion; The
documentation/records system clearly
x
identifies the maintenance retention period,
and disposition of records; and, Employees
have access to health and safety documents
they need to conduct job activities.
OHSMS Element 10: Operational Control (OHSAS 18001, Paragraph 4.4.6)

Status
Does your procedure (process) for Operational Controls: Action
place place place
32. Identify those operations that are associated with the identified
significant health and safety hazards consistent with your
x
organization's health and safety policy, objectives and targets?
33. Establish and maintain documented procedures to control situations
for those operations where absence of documented procedure(s)
x
could lead to deviation from your health and safety policy, objectives
and targets?
34. Plan these operations in order that they are carried out under specific
conditions, stipulate operating criteria, establish, implement and
maintain health and safety procedures related to goods and services x
used by the organization and communicate applicable requirements to
suppliers and contractors?
OHSMS Element 11: Emergency preparedness and response (OHSAS 18001, Paragraph 4.4.7)
Status
Do you establish and maintain a procedure (process) for emergency Not in Partially in In Notes
Action
preparedness and response that addresses how to: place place place
35. Identify potential emergency situations and potential accidents that

x
can have (a) risk(s) on the health and safety and how the organization
will respond?
36. Respond to actual emergency situations and accidents and prevent or
mitigate associated health and safety risks? x
37. Does your organization periodically review and, where necessary,

revise the emergency preparedness and response procedures, in x
particular, after the occurrence of accidents or emergency situations?
38. Does your organization periodically test the emergency preparedness
x
and response procedures where practicable?
Confirm that the procedures have been
updated, as appropriate, in response to new x
information or program reviews.
Question Category: Checking
OHSMS Element 12: Monitoring and measurement (OHSAS 18001, Paragraph 4.5.1)
Status
Do you establish and maintain a procedure (process) for monitoring and Not in Partially in In Notes
Action
measurement that ensures: place place place
39. Key characteristics of your operations (that can have a high health and
x
safety risk) are monitored and measured on a regular basis?
40. Information is documented to monitor performance, applicable
operational controls, and conformity with the objectives and targets of x
your organization?
41. Monitoring and measurement equipment is calibrated and maintained
x
and all associated records are retained?
OHSMS Element 13: Evaluation of compliance (OHSAS 18001, Paragraph 4.5.2)

Status
Action
place place place
42. Does your procedure (process) to meet the organization's commitment Legal compliance audit
to compliance ensure that you periodically evaluate compliance with needs to be carried out
x
applicable health and safety legal requirements and other health and
safety requirements to which the organization subscribes?
OHSMS Element 15: Nonconformity, corrective and preventive action (OHSAS 18001, Paragraph 4.5.3)
Status
place place place
Action
43. Do you establish and maintain a procedure (process) for Incident
reporting and Investigation and taking corrective and preventive x
actions?
44. Do you establish and maintain a procedure (process) for controlling
x
non-conformities and taking corrective and preventive actions?
45. Does the procedure for controlling non-conformities and taking
corrective and preventive action ensure that:
x
Actual non-conformity(-ies) are identified and corrected and their
health and safety risk(s) are mitigated?
Actions are determined to eliminate the causes of actual and
x
potential non-conformities and to prevent their recurrence?
Are any measures taken to identify, correct, mitigate, prevent or
eliminate the nonconformity(-ies) consistent with the magnitude of the x
problems and the health and safety risks encountered?
46. After corrective and preventive actions have been taken, are they CAPA reports needs to
reviewed and the program adjusted accordingly by implementing and x be filled for all non-
documenting any new changes that result from the findings? compliances
OHSMS Element 16: Control of Records (OHSAS 18001, Paragraph 4.5.4)

Status
place place place
Action
47. Has your organization created and maintained records as necessary
that demonstrate compliance with the OHSMS and conformance to
the requirements of the OHSAS 18001 Standard, including evaluation
of compliance with health and safety legal requirements and other x
health and safety requirements to which the organization subscribes
and the implementation of procedures and results achieved?
48. Does your procedure (process) for records management describe how Responsibilities to be
the records will be identified, stored, protected, retrieved, retained, and x asigned for each record
disposed?
49. Are the records themselves legible, identifiable, and traceable? x
OHSMS Element 17: Internal audit (OHSAS 18001, Paragraph 4.5.5)

Status
Does your procedure (process) for an internal health and safety Not in Partially in In Notes
Action
management system audit: place place place
50. Ensure that internal health and safety management system audits
x
are conducted at planned intervals?
Determine whether the health and safety management system
conforms to planned arrangements for health and safety management
x
including the requirements of the OHSAS 18001 Standard?
Determine whether the health and safety management system has Internal audit needs to be
x
been properly implemented and is maintained? carried out and recorded
Determine whether the health and safety management system
x
provides information on the results of audits to management?
51. Plan, establish and maintain the health and safety management audit Internal audit plan needs
program taking into consideration the health and safety importance of x to be rpepared
the operation(s) concerns and the results of previous audits?
52. State the responsibilities and requirements for planning and
x
conducting audits?
State the responsibilities and requirements for reporting results? x
Define the audit criteria, scope, frequency and methods and explain
x
how you have determined them?
53. Ensure that the selection of auditors and the conduct of the audits
x
maintains the objectivity and impartiality of the audit process?
Question Category: Management Review
OHSMS Element 18: Management review (OHSAS 18001, Paragraph 4.6)
Status
Does your procedure (process) for Management Review: place place place
Action
54. Ensure continuing suitability, adequacy, and effectiveness of the MRM plan needs to be
health and safety management system through top management x prepared
review of it at planned intervals?
55. Ensure that opportunities are assessed for improvement and the need
for changes to the health and safety management system including
x
the health and safety policy and health and safety objectives and
targets are assessed?
Ensure that the results of the management reviews are documented?
x
56. Contain input which includes the following: results of health and safety
management system audits, communication from external interested
parties, the performance of the health and safety management
system, the extent to which objectives and targets have been met, x
status of corrective and preventive actions, follow-up actions from
previous management reviews, changing circumstances, and
recommendations for improvement?
57. Ensure that the outputs from the management review include any
decisions and actions related to possible changes to the health and
x
safety policy, objectives and other elements of the health and safety
management system, consistent with the commitment to continual
improvement? Confirm that a review process exists to update
the policy and to communicate changes to x
appropriate stakeholders.
Program Totals
Element subtotals: 0 14 100
Program Total: 114 170 points available
Total Program percentage complete: 67%
100
80
% Complete
60
40
20
OHSAS 18001:2007 OHSMS Elements

OHSAS 18001 Audit Checklist

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OHSMS Gap Analysis

Facility Type: Auditor:

Conducting the OHSMS Gap Analysis

Gap Analysis Background

Gap Analysis Questionnaire Description and Directions

Not in place = 0 points Partially in place = 1 point In place = 2 points

Question Category: health and safety policy

Is there a risk assessment process to

15. Establishing and maintaining documented health and safety objectives

Interview staff from various operating

OHSMS Element 7: Communication (OHSAS 18001, Paragraph 4.4.3)

28. The organization's decision on whether to communicate externally on

OHSMS Element 8: Documentation (OHSAS 18001, Paragraph 4.4.4)

OHSMS Element 9: Control of Documents (OHSAS 18001, Paragraph 4.4.5)

OHSMS Element 10: Operational Control (OHSAS 18001, Paragraph 4.4.6)

35. Identify potential emergency situations and potential accidents that

37. Does your organization periodically review and, where necessary,

OHSMS Element 13: Evaluation of compliance (OHSAS 18001, Paragraph 4.5.2)

OHSMS Element 16: Control of Records (OHSAS 18001, Paragraph 4.5.4)

OHSMS Element 17: Internal audit (OHSAS 18001, Paragraph 4.5.5)

OHSAS 18001:2007 OHSMS Elements

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