Facility: Process(es) Covered: HHS(s): Completion Score History Date Part A Score Part B Score xx/xx/xxxx xx% xx% A. PROCEDURE/POLICY REVIEW Documents Reviewed Date Reviewed Title of Document Rev. # Date # Pgs. 1) CONDUCTING THE AUDIT NAC Ref. Resp. Code Item #1 Completion Score – Weighted 30% of Part A x / 2 = xx% i. Does the program procedure require that the audit be conducted and the evaluation certified at least once every three years; and does the procedure define the responsible individual who certifies the evaluation? 459.95427(1a) 459.95341 ii. Does the program procedure define the review criteria, acceptance criteria, and responsible individual(s) who conduct the review of each of the following elements: 459.95427(1a) 459.95341 a. Process Safety Information 459.95341 b. Process Hazard Analysis 459.95341 c. Standard Operating Procedures 459.95427(1a) 459.95341 d. Training 459.95427(1a) 459.95341 e. Mechanical Integrity 459.95427(1a) 459.95341 f. Management of Change 459.95427(1a) 459.95341 g. Pre-Startup Safety Review 459.95427(1a)
h. Verification of Compliance Audit 459.95341 i. Incident Investigation 459.95427(1a) 459.95341 j. Employee Participation 459.95427(1a) 459.95341 k. Hot Work Permit 459.95427(1a) 459.95341 l. Contractor Program 459.95427(1a) 459.95341 m. Emergency Response Program 459.95427(1a) 459.95341 Notes/Comments Pertaining to Responses to Questions under Issue 1): 2) PERSON CONDUCTING THE AUDIT NAC Ref. Resp. Code Item #2 Completion Score – Weighted 30% of Part A x / 1 = xx% i. Does the program procedure require that the audit be conducted by at least one person that is knowledgeable in the process being audited; and does the procedure define the criteria for auditor selection? 459.95427(2) 459.95341 Notes/Comments Pertaining to Responses to Questions under Issue 2): 3) REPORT AND RECOMMENDATION TRACKING NAC Ref. Resp. Code Item #3 Completion Score – Weighted 30% of Part A x / 4 = xx% i. Does the program procedure require that a report of the findings be generated; and does the procedure define the individual(s) responsible to generate the report? 459.95427(1b) 459.95341 ii. Does the program procedure require that appropriate responses to deficiencies be determined and documented; and does the procedure define how responses are generated and the individual(s) responsible? 459.95427(1c) 459.95341 iii. Does the program procedure require that actions taken to correct deficiencies be documented; and does the procedure define how actions are tracked and the individual(s) responsible? 459.95427(1d) 459.95341 iv. Does the program procedure require that the two most recent reports be retained?
Item #1 Completion Score – Weighted 50% of Part B x / 1 = xx% Subject Audit Were there Are all the recommendations implemented? Start Date Audit End Date Report Date Most Recent Report Previous Report Have the two most recent reports been retained? 459.95427 Pertaining to Responses to Questions under Issue 1): 2) AUDIT THE MOST RECENT VERIFICATION OF COMPLIANCE AUDIT REPORT NAC Ref. Resp. Code Item #2 Completion – Weighted 50% of Part B x / 9 = xx% Does the most recent audit report indicate that a review was performed for the program elements pursuant to the procedure review criteria: Process Safety Information 459.95427(1a) Process Hazard Analysis 459.95427(1a) Standard Operating Procedures 459.95427(1a) Training 459.95427(1a) Mechanical Integrity 459.95427(1a) Management of Change 459.95427(1a) Pre-Startup Safety Review 459.95427(1a) Verification of Compliance Audit 459.95427(1a)