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Health, Safety and Wellness Governance Procedure

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Section 1 - Purpose and Scope

(1) The University of Queensland (UQ or the University) has governance arrangements that support the management and oversight of Health, Safety, and Wellness (HSW) provisions that are underpinned by a risk-based approach. This supports the University’s commitment to health and safety, and legislative compliance with regard to the Work Health and Safety Act 2011 (Qld; the WHS Act), the Work Health and Safety Regulation 2011 (Qld; WHS Regulation), and other relevant health and safety laws. 

(2) The Procedure applies to all members of the UQ community and should be read in conjunction with the:

  1. policies, procedures and guidelines related to health, safety and wellness governance and consultation, including:
    1. Health, Safety and Wellness Policy;
    2. Health and Safety Consultative Mechanisms Procedure;
    3. Health, Safety and Wellness Audit Procedure; and
    4. Health and Safety Responsibilities Procedure;
  2. Governance and Management Framework Policy;
  3. Enterprise Risk Management Framework Policy; and
  4. Compliance Management Policy.

(3) UQ’s Health, Safety and Wellness governance mechanisms are further detailed on the HSW website.

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Section 2 - Process and Key Controls

(4) Health, safety and wellness (HSW) governance mechanisms are aligned with the Governance and Management Framework Policy and are underpinned by principles and requirements of enterprise compliance and enterprise risk management policies and frameworks. HSW Division governance mechanisms ensure reporting is integrated within UQ’s wider governance mechanisms.

(5) The UQ Health, Safety and Wellness Strategy is aligned with the UQ Strategic Plan.

(6) UQ manages its health and safety risks in accordance with regulatory requirements and the Risk Appetite Statement (RAS) approved by Senate.

(7) HSW governance and consultation policies and procedures support governance arrangements to ensure controls are in place to manage risks, report on and evaluate performance, monitor, and assure compliance.

(8) UQ has mechanisms in place to consult, cooperate and coordinate activities as required under the WHS Act.

(9) Management is responsible for leading health, safety, and wellness in their areas of responsibility with the support of the Health, Safety and Wellness Division (HSW Division) and UQ Safety Network.

(10) Reporting and monitoring provisions are in place to provide assurance to senior management on HSW compliance and the effective management of risks.

(11) A range of auditing and review mechanisms are in place to ensure periodic independent evaluation and reporting on HSW governance arrangements and related provisions.

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Section 3 - Key Requirements

Management and Accountability Structures and Processes


(12) UQ’s Senate-approved Health, Safety and Wellness Policy establishes UQ's overall health, safety and wellness objectives and demonstrates the Senate's and the Vice-Chancellor and President's commitment to continual improvement of UQ's health and safety performance and culture. The Policy outlines roles, responsibilities and accountabilities, and monitoring, review and reporting arrangements. HSW governance structure, processes and accountabilities are aligned with UQ’s organisational, governance and corporate management policies and procedures.

Health, Safety and Wellness Division (HSW Division)

(13) UQ’s HSW Division oversees HSW risk management and regulatory compliance for UQ’s regulated activities, including, research, education, and corporate operations. The Director, Health Safety and Wellness reports to the Chief Operating Officer and reports regularly to the Senate Risk and Audit Committee (SRAC) through the Vice-Chancellor's Risk and Compliance Committee (VCRCC).

(14) The HSW Division is supported by a distributed network of HSW professionals and practitioners working across UQ Organisational Units (e.g. Faculties, Institutes and Centres). The senior HSW positions in these Organisational Units have an indirect reporting line to the Director, Health Safety and Wellness as the functional lead.

UQ Institutional Biosafety Committee (IBC)

(15) The UQ Institutional Biosafety Committee is a legislated governance committee that oversees the assessment of all UQ proposals for dealings with genetically modified (GM) material in accordance with the Gene Technology Act 2000 (Cth), the Gene Technology (Queensland) Act 2016 (Qld), and other related statutes. The IBC and its sub-committee evaluate low-risk contained dealings that do not require case-by-case consideration by the regulator (Office of the Gene Technology Regulator) and reviews GM organism licence applications prior to submission to the regulator. The sub-committee also evaluates work conducted with potentially hazardous or infectious biological material.

(16) The Chairperson of the IBC reports directly to the Vice-Chancellor on IBC matters. The Chairperson also reports on IBC business outcomes to VCRCC.

Consultative Structures

(17) Health, Safety and Wellness Committees at each Faculty, Institute and Centre level meet UQ’s legislative consultative obligations and provide the opportunity for raising and dealing with health, safety and wellness issues.

(18) The Health and Safety Consultative Mechanisms Procedure is the formal procedure by which workers are involved and consulted about health and safety matters, related issues and any proposed changes to the work environment, processes and practices that may impact on health and safety.

(19) The HSW Division supports and guides HSW Committees as UQ’s formal consultative structure for health, safety and wellness matters and issues.

(20) UQ supports the appointment and election of health and safety representatives across UQ, in accordance with the WHS Act and WHS Regulation, and ensures that their legislative entitlements are maintained.

Audit Programs

HSW Internal Audit Program 

(21) The HSW Division undertakes an annual HSW internal audit program that is endorsed by VCRCC. The objective of the program is to monitor the effectiveness of the UQ’s Occupational Health and Safety Management System (OHSMS), which supports UQ’s maintenance of its self-insurance licence for workers’ compensation, and to facilitate ongoing improvement. The audit program extends to UQ’s controlled entities and is implemented according to the Health, Safety and Wellness Audit Procedure.

(22) Outcomes are regularly reported to UQ Senior Management (through VCRCC, the University Senior Executive Team and to the SRAC). Implementation of corrective actions are monitored until all items are addressed.

UQ Independent and External Audit Program

(23) UQ is self-insured for workers’ compensation and therefore subject to periodic external audits of its occupational health and safety management systems by an external accredited third-party auditor. Results of these audits are reported to the Queensland work health and safety regulator and the workers’ compensation regulator.

(24) In addition to external audits, the UQ HSW function may be subject to other independent audits undertaken by UQ’s Internal Audit Group that report directly to the Vice-Chancellor.

Regulator Audits

(25) Other regulators (e.g. Commonwealth Department of Agriculture, Water and Environment, and the Office of Gene Technology Regulator) will monitor performance through regular inspections and audits. The Office of Gene Technology Regulator receives a formal report from UQ annually regarding its relevant compliance requirements. 

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Section 4 - Roles, Responsibilities and Accountabilities


(26) Senate is the University's governing body and accountable for the effective and efficient governance of the University. Senate approves the UQ Enterprise Risk Management Framework, the University's Risk Appetite Statement, and the Health, Safety and Wellness Policy. Specific HSW duties are set out in the UQ Health and Safety Responsibilities Procedure.

Senate Risk and Audit Committee (SRAC)

(27) The Senate Risk and Audit Committee (SRAC) exercises oversight of the University’s governance, risk and compliance frameworks including policies, procedures, information systems and systems of internal control surrounding key operational processes including HSW. The Committee also provides oversight of the leadership and direction in terms of organisational culture and ethical behaviour.

(28) SRAC receives and reviews reports and assurances on the University’s framework and processes to demonstrate compliance with its legal and regulatory obligations, including any material breaches and/or regulatory actions against the University.

Vice-Chancellor's Risk and Compliance Committee (VCRCC)

(29) The Vice-Chancellor's Risk and Compliance Committee (VCRCC) provides advice and recommendations to the Vice-Chancellor and SRAC. The committee provides oversight of the implementation of any directives in relation to governance, risk and compliance to address any systemic issues or to further enhance controls and culture that include HSW.

UQ Senior Management

(30) UQ Senior Management is responsible for health and safety risk management, including monitoring and reviewing their operational activities, health and safety risks and controls to ensure effective risk management and compliance.

Health, Safety and Wellness Division (HSW Division)

(31) The UQ Health, Safety and Wellness Division has the primary responsibility for establishing and monitoring UQ HSW governance arrangements, the OHS management systems, and providing specialist HSW services and advice. It supports management in meeting UQ’s health and safety obligations and driving enhanced health and safety outcomes for its workers and students.

General Responsibilities and Accountabilities

(32) The detailed responsibilities and accountabilities of UQ positions with respect to health and safety are outlined in UQ’s Health and Safety Responsibilities Procedure. The roles, responsibilities and accountabilities which reflect relevant legislative responsibilities are outlined in the Procedure.

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Section 5 - Monitoring, Review and Assurance

UQ Senior Management

(33) UQ Senior Management will monitor and review the HSW routine processes, procedures, systems and activities of front-line operations. These activities take the form of, but are not limited to, the establishment and review of HSW management plans (including goals and measures), local safety risk registers and consultative committees. 

Health, Safety and Wellness Division (HSW Division)

(34) The HSW Division will monitor and review health and safety risks across UQ and facilitate the ongoing effectiveness of the occupational health and safety management system. The HSW Division will be supported in this effort by management and the HSW network. The HSW Division will provide an assurance function to senior management through its auditing regime and performance monitoring and reporting.

(35) The Governance and Risk Division monitors, evaluates, and reports on HSW performance and the currency of HSW policies, procedures and related provisions.

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Section 6 - Recording and Reporting

Management Reporting

(36) The Health and Safety Management Reporting Procedure outlines management reporting arrangements with respect to health, safety and wellness matters. Reports are provided to each of the following groups:

  1. Vice-Chancellor's Risk and Compliance Committee;
  2. University Senior Executive Team (USET); and
  3. Senate Risk and Audit Committee.

(37) Monthly reports are also provided to UQ’s HSW network, HSW Committees and UQ Senior Managers.

HSW Division Reporting

(38) The HSW Division provides performance information with respect to its set health, safety and wellness goals and measures, as well as an assessment of UQ’s safety risk position on a regular basis to senior management. These reports include performance of local areas with respect to UQ wide health, safety and wellness goals and measures. They include outcomes of health, safety and wellness internal and external audits, the progress toward implementing audit recommendations, contentious issues, significant incidents, and workers’ compensation information.

(39) In addition to regular monthly reports, the HSW Division compiles a detailed annual report on health, safety and wellness performance, risk position and activities for senior management. A version of this report is distributed to and posted on the UQ HSW website. Refer to the Health and Safety Management Reporting Procedure for further details.

Institutional Biosafety Committee (IBC) Reporting

(40) The Chair of the UQ Institutional Biosafety Committee (IBC) reports directly to the Vice-Chancellor and the VCRCC on IBC related matters. The Chair of the IBC is a member of VCRCC. The HSW Division provides secretariat support to the IBC and its sub-committee, as well as advisory and technical support as required.

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Section 7 - Appendix

Definitions, Terms, and Acronyms

Term Definition
Compliance Obligation A compliance obligation includes externally imposed obligations that are established through law/legislation, regulations, codes, professional standards, and other licensing or contractual obligations; and internally approved UQ policies and procedures that assure regulatory compliance.
Faculty/Institute HSW Committee Includes Faculty, Institute, Division and Central Support Services HSW Committees
UQ Community Includes current UQ students, staff (whether or not those staff are covered by the University of Queensland Enterprise Agreement 2021-2026, or as amended or replaced), volunteers, affiliates, associates, and anyone else contractually bound to comply with the Policy.

Key Related Policy Areas

(41) This Procedure should be read in conjunction with the UQ:

  1. Health, Safety and Wellness Policy and related policies, procedures and guidelines;
  2. Governance and Management Framework Policy;
  3. Compliance Management Policy; and
  4. Enterprise Risk Management Framework Policy.

Health, Safety and Wellness Governance Structures

(42) See linked Health, Safety and Wellness Governance Structures diagram.