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Health and Safety - Document Control Procedure

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Section 1 - Summary

(1) The purpose of this Procedure is to outline the process for creating and maintaining Health, Safety and Wellbeing documentation for the Victoria University (VU) Health, Safety & Wellbeing Management System. 

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Section 2 - TEQSA/ASQA/ESOS Alignment

(2) HESF – Standard 2.3 Wellbeing and Safety; 7.3 Information Management.

(3) Standards for Registered Training Organisations (RTOs) 2015 (Cth): Standard 8.

(4) ISO 45001:2018 – Clause 7.5 and ISO 45003:2021 – Clause 7.5.

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Section 3 - Scope

(5) This Procedure applies to all documents and records created as part of the Victoria University’s Health, Safety & Wellbeing Management System (HSWMS).

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Section 4 - Definitions

(6) Department: Divisions, Departments, Faculties, Institutes and Offices, other than OHS Team, preparing OHS document for their specific usage, not relevant to rest of the University. 

(7) Department Document Owner: The person responsible to manage the create/edit/review/approval process for the document from their department.

(8) HSW Document Controller: The Health, Safety and Wellbeing (HSW) team member nominated for the University HSW document control requirements at an organisational level. 

(9) HSW Controlled Document: Any HSW document for which distribution and status are required to be kept current by the issuer to ensure that authorised holders or users have the most up to date version available. 

(10) HSW Document Control: The process established in this Procedure to define controls needed for the management of HSWMS documentation. 

(11) HSW Document Controller: The HSW team member nominated for the University HSW document control requirements at organizational level. 

(12) Local HSW Document: HSW documents that are created by ‘Departments’ to meet the specific local needs of that area e.g., Permit to Work Checklist, Work at Height Procedure, Safe Work Instruction – Workshop Safety etc. 

(13) Procedure: Specified way to carry out an activity or a process. 

(14) University HSW Document: HSW documents that are created by VU HSW team to be followed and used by every department, division, faculty and office e.g., HSW Policy, Communication & Consultation Procedure, First Aid Risk Assessment Form etc. 

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Section 5 - Policy/Regulation

(15) Health and Safety Policy

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Section 6 - Procedures

Part A - Summary of Roles and Responsibilities

Roles Responsibilities
Senior Manager, Health Safety & Wellbeing
The Senior Manager, Health Safety & Wellbeing will:
a.Review and approve University HSW documents;
b.Restrict the access of any document listed as having privacy or confidentiality properties;
c.Provide expert advice on local HSW documents.
HSW Document Controller In addition to the HSW team responsibilities, the HSW Document Controller is responsible for:
a.Developing documentation, assigning document control numbers and record keeping requirements for the HSW management system and Local HSW documents;
b.Non-conformance checks, as per Part B;
c.Location of HSW documents, as per Part B;
d.Obsolete documents, as per Part B.
Health Safety and Wellbeing Team (HSW Team)
The HSW Team is responsible for the following requirements of Part B:
a.Document design;
b.Document properties;
c.Creation of University HSW documents, where the topic applies to the entire University;
d.Consultation and communication;
e.Document review;
f.Documentation verification;
g.Document retention;
h.Disposal of documents; and,
i.Privacy and confidentiality of HSW records.

Part B - Document Control

Document Design

(16) Health and Safety documentation is created in the relevant University style guidelines/templates to ensure consistency with regards to style, format and document control properties. The only exceptions include:

  1. evacuation and first aid posters;
  2. safety posters;
  3. brochures.

(17) Department Document Owner will consult and seek advice from the HSW team regarding design, format and document control properties.

Document Properties

(18) HSW Document Controller will ensure all HSW documentation has the following document properties:

  1. document control number or name, in the following format:
    1. HSW–Section/Element Number-Document Type Acronym-Sequential Number- Version.  e.g., HSW-3.1-F-03-0.0 & HSW-1.9-MAN-02-1.1
    2. The HSW prefix is constant. Every HSW document number will start with HSW.
      1. Document Type Acronym
        Manual MAN
        Policy     POL
        Procedure     PR
        Safe Work Procedures SWP
        Safe Work Methods Statement SWMS
        Work Instruction WI
        Guidelines     GL
        Forms & Checklists F
  2. Current version number, as per the following:
    1. minor amendments, such as spelling, grammatical or inconsequential content changes will result in the decimal number increasing by one, e.g., after grammatical changes in document HSW-2.3-F-03-2.0, it will become HSW-2.3-F-03-2.1
    2. major amendments will result in the version number increasing by one, e.g., document HSW-1.11-GL-04-1.1, it will become HSW-1.11-GL-04-2.0
  3. Current review authorisation date.
  4. Next review date (within three years of authorised date).

(19) Document headers should be used and must include:

  1. the University logo;
  2. document title.

(20) An example of the document properties footer which should be used:

Prepared By:  Sr. Advisor H&S Date Revised: 02/03/2022 Document No: HSW-2.5-F-1-1.2
Approved By:  Sr.Mgr HS&W Next Revision Date: 02/03/2025 Page  4 of 6

Part C - Health, Safety & Wellbeing Document Creation

University HSW Documents

(21) The HSW Team shall:

  1. Create, where necessary, Health and Safety procedures, schedules, and guidelines.
  2. Consult with the Health and Safety Representatives (HSRs) when developing University HSW documents to ensure that they are consistent with the University’s Communication and Consultation requirements. 
  3. Follow the VU Policy Library guides when developing and reviewing HSW procedures, schedules and guidelines.

Local HSW Documents

(22) The Department Document Owner shall:

  1. Create, where necessary, Local HSW documents (i.e., manuals, instructional documents, checklists, forms, brochures, posters and fact sheets).
  2. Consult with the HSW team and HSRs when developing Local HSW documents to ensure that they are consistent with the University’s Communication and Consultation requirements. 
  3. Forward draft of local HSW documents to the Senior Manager, Health Safety & Wellbeing for review and approval.

Consultation and Communication

(23) All relevant stakeholders shall be consulted when developing any HSW document.

(24) Evidence of consultation e.g., meeting minutes, memorandums, emails, VU Policy Library bulletin board, etc. shall be documented.

(25) Consideration as to how the HSW document can be effectively communicated to people will occur prior to publishing the document.

Location of HSW Documents

University HSW Documents

(26) HSW team shall liaise with the relevant department to ensure HSW policies, procedures, schedules and guidelines are placed in the VU Policy Library and Webpages (Share Point).

Local HSW Documents

(27) Department Document Owner to ensure Local HSW documents are located on Department websites (Share Point).

Document Changes 

(28) If a change to a controlled document is required, all the changes must be approved through the HSW Change / New Document Form. This ensures: 

  1. Changes are made to the most recent version of the controlled document. 
  2. Amendments are clearly identified to highlight the changes between the new and the superseded version. 

(29) All major amendments that are made to controlled documents must be reviewed, consulted on and approved. 

Document Review

(30) HSW Team shall review all University HSW documents at a minimum of every three (03) years or as required due to changes in legislation, practices or a significant event.

Documentation Verification

(31) HSW Team shall conduct regular audits to ensure compliance with document control requirements. These audits support the integrity of the HSW management system by ensuring current documents and records are suitable and appropriate to the needs of those using them; and in aiding the University to achieve the objectives of the Health and Safety Policy.


(32) HSW Team shall review all existing HSW documents to ensure that they conform to these procedures, and amend any non-conforming HSW documents to ensure compliance.

Obsolete Documents

(33) Obsolete HSW documentation must be removed from relevant web pages.

(34) Departments shall inform the HSW team of the obsolete Local HSW document.

(35) HSW team shall inform relevant areas of the obsolete University HSW document.

Document Retention

(36) All documents shall be kept in accordance with the Public Records Act 1973 (Vic).

Disposal of Documents

(37) Disposal of documents shall follow the prescribed methods in the University’s Records Management - Disposal of Records Procedure.

HSW Document Control Register

(38) The VU Policy Library acts as the HSW Document control register for all HSW policies, procedures and associated documentation.

Privacy and Confidentiality of HSW Records

(39) The University's Privacy Procedure and legal requirements will be observed and applied to data and information contained in HSW records.

(40) Records which require the collection of private or confidential information shall be stored in a manner consistent with Privacy and Data Protection Act 2014 (Vic), and in accordance with the Health Records Act 2001 (Vic).

(41) Access to any document listed as having privacy or confidentiality properties shall be restricted to personnel with legitimate business needs. Requests for access to these documents are to be made in writing to the Senior Manager, Health Safety & Wellbeing.