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1 Procedure: Control of Documents Facilities and Services Division 1. SUMMARY 1.1. This procedure defines the requirements for the creation, numbering, review, approval, distribution, use and revision of F&S quality management system documents This procedure applies only to documents which instruct F&S staff on how to carry out activities and tasks; this includes manuals, procedures, forms and instructional sheets or posters. Documents outside of this scope do not require control Configuration management is defined in the documented procedure Configuration Management. 2. REVISION AND APPROVAL This procedure is released and approved as follows. Rev. Date Nature of Changes Approved By 0 11/07/2016 Original Issue Darren Knights 3. PROCEDURE 3.1. Each QMS manual page, procedure page, work instruction page, guide and reference page, form and register is to carry a unique identification consisting of: Document Reference Number, Revision Number, Document Title, and Page Number of all pages e.g. Page X of Y (optional on single page forms and single page registers) 3.2. Creation of Documents Documents are created by an appropriate subject matter expert All internal documents are created as soft files (MS Word, etc.); it is recommended that files of a similar type follow the format of other documents in that type Draft versions must then be sent to the appropriate approver(s) for review and approval Document Reference Number The Document Reference Number consists of a set of letters and numbers which categorise and classify the document by its purpose, what it belongs to and where it sits within the overall system of documents. Page 1 of 5
2 The Document Reference Number that has been implemented for the F&S QMS is QMS-FS-XXX-YY-ZZZ QMS identifies the document as part of the Quality Management System. This has been included to allow for future expansion of the document numbering system to cover other systems such as the Workplace Health & Safety (WHS) management system in compliance with AS/NZS ISO 4801 and an Environmental Management System (EMS) in compliance with AS/NZS ISO FS identifies that the document is a part of the Facilities & Services Division QMS. This has been included to allow for future expansion of the document numbering system to cover other Service Divisions and Colleges within the University XXX is the abbreviation for the document type, and YY is the Numerical Prefix of the applicable F&S Business Unit ie. 44 for Gardens & Grounds. The Numerical Abbreviations for the F&S Business Units are detailed in the Table below: F&S PORTFOLIO / BUSINESS UNIT ABBR PREFIX F&S MANAGEMENT SYSTEM FSMS 00 Quality Management System QMS 10 Work, Health and Safety (Future Use) WHS 20 Environmental Management System (Future Use) EMS 30 OPERATIONS OPS 40 Remote Sites REM 41 Security SEC 42 Cleaning, Waste and Recycling CWR 43 Gardens and Grounds G&G 44 Sustainability Office SO 45 Communications COMM 46 PROJECTS PROJ 50 Project Delivery PD 51 Space Management SM 52 MAINTENANCE MAINT 60 Service Delivery Team SDT 61 Engineering and Technical Services E&TS 62 Client Relationship Team CRT 63 Program Delivery PROG 64 CORPORATE AND CLIENT SERVICES CCS 70 Governance and Reporting G&R 71 Finance FIN 72 Contracts CON 73 Administration Services ADMIN 74 Teaching and Learning Commons Support Services TLCSS 75 Commercial Services CS 76 Page 2 of 5
3 ZZZ is the Document Sequence Number starting at 001. The Document Type abbreviations used in the Document Reference Number are detailed in the table below: Document Type Abbreviation Comments Policies POL Numbering starts at 001 Manuals MAN Numbering starts at 001 Process Flows PRF Numbering starts at 001 Procedures PRO Numbering starts at 001 Work Instructions WIN Numbering starts at 001 Forms FRM Numbering starts at 001 Guides GUI Numbering starts at 001 Registers REG Numbering starts at 001 Records REC Numbering starts at Document Revision Number During initial drafting, documents use sequential alphabetic characters for each revision number, e.g. QMS-FS-MAN-001 Rev A Following approval of the first issue, documents use sequential numeric characters for each revision number, starting at 0 for the initial issue, e.g. QMS-FS-MAN-001 Rev Draft changes to issued documents use sequential alphabetic characters following the current version number, e.g. QMS-FS-MAN-001 Rev 0A Review and Approval The Quality Manual may only be approved by the Director Facilities and Services Division. Other documents are to be approved by the original author, an appropriate area manager or a member of the F&S Senior Management Team Draft files may be sent to the approver(s) via hardcopy or The reviewer will resolve any issues with the original author to achieve a satisfactory document The reviewer will indicate approval of the document by providing approval confirmation via to the document author The approved document shall then be forwarded to the F&S Document Controller. Page 3 of 5
4 The F&S Document Controller will maintain a computer folder, on the Division server, for the latest soft copy versions of document. This fileset must be on a server subject to data backup. The F&S Document Controller will place new or revised documents into that folder, setting each file s permission to READ ONLY, or converting the released versions to a noneditable file format Any previous soft versions are then moved to a separate folder identified for obsolete documents which are kept for historical purposes The directory of official released documents shall act as a master list of documents, indicating the current versions of all documents. No other master list is required Distribution of Documents Controlled documents will be available via the intranet for all employees. Employees receive training on the file and folder locations for most current documents Re-Evaluation Documents must be reviewed by the original author or another subject matter expert or SMT member every three years The F&S Document Controller will ensure re-evaluation is conducted and that documents are updated if required. The F&S Document Controller will maintain a record of document re-evaluations, to identify when documents are due for re-evaluation If a document is determined to require updating, the changes shall be made and a new version issued per the rules below If a document is determined not to require updating, no action on the document is necessary Revising Documents Changes to documents go through the same steps as original issue, except that their revision level is advanced upon approval Only authorized personnel may change documents, although any employee can request a change to their Manager, or by filing a Corrective Action Request. Wherever possible, the document shall include a change history table within its text. Forms do not require a revision history table Any changes to documents that require customer or regulatory authority review and approval shall be submitted accordingly, and not implemented until such approval is obtained If document changes require customer or regulatory approval prior to implementation, this will be obtained in writing. When processes are changed, the appropriate documentation shall be updated, with a change history updated to reflect the reason for the change Re-evaluation, inspection (where applicable) and internal auditing will confirm the effectiveness of changes. Page 4 of 5
5 3.9. Controlling Documents of External Origin For external documents such as standards or third party specifications which are referenced in a customer purchase order or contract, these documents may be maintained without control, provided that the revision of the document on file matches the revision indicated by the customer. Where the customer provides no revision number, the latest (most recent) revision shall be assumed For external documents such as standards or third party specifications which are not referenced in a customer purchase order or contract, these must be controlled. Such control requires that the F&S Document Controller or responsible manager obtain the latest version of the document, and maintain it on the Division server. Like other controlled documents, these may not be edited or copied Third party specifications and prints, including those of the customer, are controlled per the configuration management requirements set forth in the F&S Quality Manual External documents for non-critical use, such as user manuals, reference books, marketing materials, and supplier directories are not controlled Forms Forms are a special kind of document that may be photocopied as needed. Furthermore, forms do not require an approval signature; Business Unit managers are responsible for creating and using forms in their areas A softcopy of each approved form must be sent to the F&S Document Controller for inclusion in the document control area on the intranet, and for inclusion in the Document Master List. Page 5 of 5
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