Procedure 14-1

Adoption
Date: 2010-07-14
Instance of approval: Vice-President, Resources

Modifications
Date: 2016-03-16
Instance of approval: Vice-President, Resources
Date: 2022-09-26
Instance of approval: Vice-President, Finance and Administration

Responsible Department: Office of the Chief Risk Officer

1. PURPOSE

   This procedure complements Policy 77 — Occupational Health and Safety, which establishes the University policy on occupational health and safety. It defines occupational health and safety roles and responsibilities as they apply to members of the University community and outlines the University health and safety accountability structure. While responsibility and authority can be assigned, executive management is ultimately accountable for the development, implementation and functioning of the University’s occupational health and safety management system.

2. INTERPRETATION AND DEFINITIONS

   This procedure and the definitions set out below must be read in conjunction with the applicable health and safety legislation, principles set out in the University’s occupational health and safety policy, and the applicable collective agreements governing employment conditions.

   “Accident” means an unexpected event causing injury, illness or death (see also critical injury) or involving a person’s exposure to harmful substances.

   “Applicable health and safety legislation” means those statutes and regulations governing occupational health and safety that apply to the University, such as the Ontario Occupational Health and Safety Act and its regulations, as amended from time to time, or similar legislation enacted respecting occupational health and safety.

   “Competent person” means a person who,

   1. is qualified because of knowledge, training and experience to organize the work and its performance;
   2. is familiar with the applicable health and safety legislation that applies to the work; and
   3. has knowledge of any potential or actual danger to health and safety in the workplace.

   “Contractor” means an individual, company or other entity hired by the University (or representative) to provide services, and includes a constructor as defined in the applicable health and safety legislation.

   “Critical injury” means an injury of a serious nature that:

   1. Places life in jeopardy;
   2. Produces unconsciousness;
   3. Results in substantial loss of blood;
   4. Involves the fracture of a leg or arm, but not a finger or toe;
   5. Involves the amputation of a leg, an arm, a hand or a foot, but not a finger or toe;
   6. Consists of burns to a major part of the body; or
   7. Causes the loss of sight in an eye.

   “Department chair” means the titular head and chief administrator of a department within a faculty.

   “Directive” or “procedure” means a University practice, instruction or process to outline specific courses of action or explain how to apply a University policy or applicable health and safety legislation.

   “Employee” has a similar meaning to “worker.”

   “Employer” means the University or a person who employs a worker or contracts for the services of a worker and includes a contractor or subcontractor who performs work or supplies services. The University of Ottawa is an employer. Individuals may also be considered employers under applicable health and safety legislation.

   “Executive management” means the officers and executives accountable for the overall governance and management of the institution (e.g., President and VPs). The President established the Administration Committee, which is responsible for the internal management of the University and for the general administration of University business, in keeping with applicable laws and regulations, including occupational health and safety. The Administration Committee reports to the President, who is responsible for making the necessary recommendations to the Board of Governors.

   “Facility manager (or equivalent)” means the support person for the building infrastructure and associated systems (e.g., HVAC, water, electrical, architecture, compressed air, gas, space, etc.).

   “Health, safety and risk assistant (HSRA)” means the support person for a health, safety and risk manager.

   “Health, safety and risk manager (HSRM)” means a staff person for risk, environment and health and safety matters in higher-risk faculties or services within the University.

   “Higher-risk workspace” means a laboratory, workshop, industrial or other workplace in which the hazards therein create an elevated risk of injury, exposure or illness.

   “Incident” means an undesired event resulting in damage to property or the environment, for example, a fire, spill, or breakage of material.

   “Internal responsibility system” or “IRS” means the University’s accountability framework for occupational health and safety matters, as set out in this procedure.

   “Multi-Site Joint Occupational Health and Safety Committee” means the committees established by the University as a consultative, joint forum for workers and management to review and recommend to the employer improvements to the occupational health and safety program.

   “Near miss” means an incident that did not have consequences. However, the potential for injury, harm, or damage existed.

   “Occupational illness” means a condition that results from exposure in a workplace to a physical, chemical or biological agent to the extent that normal physiological mechanisms are affected, and the health of the worker is impaired. It includes an occupational disease for which a worker is entitled to benefits under the Workplace Safety and Insurance Act, 1997.

   “Office of the Chief Risk Officer” means the part of the organizational office responsible for institutional occupational health and safety at the University of Ottawa.

   “Senior management” means the most senior management personnel within a faculty or service. It includes associate vice presidents, vice provosts and deans.

   “Student” means a person who is enrolled in a course or program of study and/or research endeavour at the University who is not performing work or supplying services to the University. A student may be at an undergraduate or graduate level.

   “Supervisor” means a person who has charge of a workplace or authority over a worker or another person. The determination as to whether a person is a supervisor does not depend on that person’s job title. Rather, it depends on whether the person is responsible for a location (for example, an office or laboratory) where work is performed on a paid or unpaid basis or whether the person gives direction to complete work performed by workers, students, visitors or volunteers. Depending on the workplace relationship, a supervisor may include, for example, the President, vice-presidents, directors, deans, chief administrative officers, managers, professors or principal investigators.

   “University community” means the collective members and stakeholders of the organization, including workers, supervisors, managers, senior management, executive management, students, visitors, volunteers, contractors, etc.

   “Worker” means any of the following:

   1. a person who performs work or supplies services for monetary compensation. This means any University employee and includes a person who performs work or supplies services for monetary compensation. Students hired by the University to perform paid work-study program duties or co-operative education placement duties for the University are considered workers; 
   2. a secondary school student who performs work or supplies services for no monetary compensation under a work experience program authorized by the school board that operates the school in which the student is enrolled;
   3. a person who performs work or supplies services for no monetary compensation under a program approved by a college of applied arts and technology, university or other postsecondary institution;
   4. such other persons as may be prescribed who perform work or supply services to an employer for no monetary compensation.

   “Visitor” or “volunteer” refers to a person who is not a worker or a student but who performs work at the University workplace for other reasons, which are typically associated with personal education, training or experience. For greater clarity, the duties of “workers” apply to visitors and volunteers. The duties of “supervisor” apply to those who supervise visitors and volunteers.

3. INTERNAL RESPONSIBILITY SYSTEM

   1. UNIVERSITY

      As an employer, the University has a general duty to take every precaution reasonable in the circumstances to protect the health and safety of a worker. Due diligence is the level of judgment, care, prudence, determination and action that a person would reasonably be expected to offer under particular circumstances. The University, as an employer and having regard for the protection of workers, and without limiting the requirements imposed by applicable health and safety legislation, will ensure:

      1. that equipment, materials and protective devices are provided and maintained in good condition, and that they are used as prescribed under the applicable health and safety legislation. When allowed by the granting agency, equipment, materials and protective devices required for research projects will be paid from the grant supporting the research project;
      2. that the health and safety measures and procedures prescribed are carried out in the workplace;
      3. that information, instruction, training and supervision are provided to workers to protect their health and/or safety;
      4. that when appointing supervisors, they are competent with respect to their responsibilities under applicable health and safety legislation
      5. that assistance and co-operation are provided to the multi-site joint occupational health and safety committees in fulfilling their responsibilities under applicable health and safety legislation
      6. that the multi-site joint occupational health and safety committees are provided with the results of reports prepared respecting occupational health and safety
      7. that workers are advised of the results of occupational health and safety reports;
      8. that control measures are in place to safeguard workers from undue exposure to biological, chemical, physical, biomechanical or psychosocial hazards as prescribed under applicable health and safety legislation;
      9. that workers are provided with written instructions as to the measures and procedures to be taken for the protection of workers, where prescribed in applicable health and safety legislation;
      10. that such training programs are carried out for workers, supervisors and multi-site joint occupational health and safety committee members as may be prescribed under applicable health and safety legislation and that work is carried out according to the established internal directives;
      11. that the workplace is monitored to ensure that workers follow the applicable health and safety legislation, policies, standards and directives.

   2. EXECUTIVE MANAGEMENT

      Executive management is ultimately accountable for University occupational health and safety and ensuring the responsibilities of the organization are fulfilled. 

      Executive management will:

      1. Set the institutional policy relating to the health and safety management system;
      2. Retain overall accountability for the health and safety management system;
      3. Ensure that all established health and safety policies are administered and enforced in all areas;
      4. Ensure that all personnel are aware of, and effectively practise, the policies and procedures set out in the health and safety management system;
      5. Ensure that appropriate resources are available for the health and safety management system;
      6. Ensure that the appropriate systems are in place to address accountability for health and safety performance at the faculty or service level.

   3. OFFICE OF THE CHIEF RISK OFFICER

      The Office of the Chief Risk Officer provides institutional occupational health and safety support to the University community to ensure that the occupational health and safety management system is implemented and monitored on behalf of executive management. 

      As part of its mandate, the Office of the Chief Risk Officer develops, assures and reports on University‐wide health, safety, risk and environmental management policies, procedures, plans and programs. 

      In addition, it provides technical and specialized services to support operational practices on behalf of the University, such as coordinating disposal of biohazardous, chemical and radioactive materials, providing information and training, and conducting assessments including inspections and health and safety audits. 

      As part of the Office of the Chief Risk Officer, health and safety professionals will:

      1. Develop the organizational occupational health and safety framework, including goals, objectives and targets to coordinate and manage institutional initiatives;
      2. Measure occupational health and safety performance across the University and provide insights for continual improvement;
      3. Provide second-line assurance for the faculties and services to ensure compliance to the requirements of the occupational health and safety management system;
      4. Manage University-wide occupational health and safety processes and services, and establish recommended practices for occupational health and safety processes;
      5. Establish and define the minimum requirements for occupational health and safety training;
      6. Manage and coordinate University-wide occupational health and safety regulatory changes and issues; 
      7. Standardize common occupational health and safety services across the organization (e.g., management of related technology and solutions, data analytics);
      8. Manage University-wide occupational health and safety-related contracts (e.g., subject matter experts, inspectors, maintenance, vendors of record, etc.);
      9. Provide subject matter expertise and support to faculties and services for occupational health and safety-related topics; 
      10. Manage governance frameworks and establishment of expectations and protocols.

   4. HEALTH, SAFETY AND RISK MANAGERS (HSRM)

      The health, safety and risk managers provide front-line dedicated support for health and safety, risk and environmental matters in higher-risk faculties and services. Following their leadership, the HSRM supports the implementation of occupational health and safety policies, procedures and practices within the faculty or service. The HSRM assists supervisors and workers in the execution of their responsibilities under the Occupational Health and Safety Act as well as University health and safety procedures and practices. Health, safety and risk managers will:

      1. Manage daily faculty- or facility-specific occupational health and safety activities and procedures based on institutionally defined practices and expectations;
      2. Provide first-line assurance;
      3. Monitor and deliver minimum training needs;
      4. Manage and deliver additional training based on relevant hazards and risks;
      5. Provide input on best practices and feedback for the occupational health and safety management system;
      6. Gather data and statistics to support institutional performance measurement;
      7. Receive and review incident or accident reports related to their mandate;
      8. Conduct inspections, evaluations and audits to ensure compliance and consistency of specific programs with the broader University management system;
      9. Develop and manage specialty management programs.
      10. HSRMs may be supported by health, safety and risk assistants.

   5. SENIOR MANAGERS

      Senior managers are responsible for overseeing compliance with all health and safety legislation, policies, procedures and standards established under the Occupational Health and Safety Act, or by the University, their faculties or services, or regulatory agencies. Senior managers ensure that appropriate health and safety programs are in place at the faculty or service level. 

      This includes developing, establishing and maintaining faculty or service-specific objectives, plans, programs, procedures, directives and guidelines necessary to identify, manage and control hazards and risks applicable to their faculty or service. 

      Senior managers will allocate, or if necessary request, sufficient resources to ensure the effective operation of these initiatives. They are also responsible for monitoring adherence to objectives, plans, programs, procedures, directives and guidelines established for their faculty/service. 

      Senior management is required to take corrective action, within the scope of its authority, as soon as they become aware of a situation that involves non-adherence to policy and procedures, or laws and bylaws. Situations requiring further assistance or intervention must be escalated to the appropriate vice president (e.g., Vice President Academic Affairs, Vice-Present Research and Innovation, Vice-President Finance and Administration, Vice President International and Francophonie, Vice President External Relations or the Secretary-General).

      These roles and responsibilities are in addition to those established for workers and supervisors.

   6. DEPARTMENT CHAIRS

      Department chairs are responsible for ensuring compliance with all health and safety legislation, policies, procedures and standards established under the Occupational Health and Safety Act, or by the University, their faculty or regulatory agencies at the individual department level.  
      This includes developing, establishing and maintaining department-specific objectives, plans, programs, procedures, directives and guidelines necessary to identify, manage and control hazards and risks applicable to their department. Department chairs must allocate, or if necessary, request sufficient resources to ensure the effective operation of these initiatives. They are also responsible for monitoring adherence to objectives, plans, programs, procedures, directives and guidelines established for their department.

      Department chairs are required to take corrective action, within the scope of their authority, as soon as they become aware of a situation that involves non-compliance to policy and procedures, laws or bylaws. Department chairs must report situations requiring further assistance or intervention to their dean.

      These roles and responsibilities are in addition to those established for workers and supervisors.

   7. FACILITY MANAGERS

      Facility managers are responsible for monitoring the condition of the infrastructure and building systems under their responsibility. Facility managers are management representatives for occupational health and safety matters within their area of their responsibility. Facility managers will:

      1. Be familiar with the hazards, risks and requirements of workplaces under their authority;
      2. Be familiar with and coordinate the execution of the response and incident response mechanisms in place;
      3. Monitor the physical condition of workspaces under their authority;
      4. Conduct periodic inspections of their facilities;
      5. Receive and respond to health and safety inspection reports;
      6. Coordinate the necessary repairs or modifications to building infrastructure;
      7. Communicate matters relating to health and safety to building occupants.

      These roles and responsibilities are in addition to those established for workers and supervisors.

   8. SUPERVISORS

      A supervisor has several legal obligations under the applicable health and safety legislation, including ensuring that workers comply with the Occupational Health and Safety Act, informing workers about hazards, and providing instruction to workers. The list below summarizes some of the supervisors’ legal duties. Supervisors must:

      1. Stay informed of, communicate, and apply the health and safety requirements for work and workers under their authority;
      2. Identify hazards, assess their risk of harm and incorporate preventive and control measures into all functions and activities for work under their authority;
      3. Ensure that workers under their authority work in the required manner, and with the protective devices, measures and procedures required under the applicable health and safety legislation;
      4. Ensure the safety of people or workplace areas under their authority, including advising a worker of any potential or actual health or safety dangers known by the supervisor;
      5. Before commencing new work or a new task, ensure that health and safety orientation, instruction and information are provided by a competent person to people under their authority;
      6. Ensure that workers under their authority use or wear the equipment, protective devices or clothing required;
      7. Ensure that mandatory and job-specific health and safety training is provided by a competent person to people under their authority prior to conducting the task;
      8. Provide health and safety training opportunities for all workers and people under their responsibility;
      9. Where health and safety-related training has been provided, maintain an updated list of all those who have received the training, the name(s) of the person(s) who provided the training, the date on which the training was given, the type of training provided and related training materials;
      10. Monitor the health and safety performance of their workers and institute corrective action, when required;
      11. Periodically inspect the workplace under their authority and take corrective action within the scope of their responsibility;
      12. Provide assistance and co-operation to the multi-site joint occupational health and safety committee members in the carrying out of their functions as stipulated under the Occupational Health and Safety Act and the terms of reference;
      13. Report all accidents, incidents, occupational illnesses and near misses in accordance with the internal procedure; 
      14. Investigate all accidents, incidents, occupational illnesses and near misses to ensure appropriate and necessary action is taken to identify the root cause and institute corrective action(s);
      15. Ensure that any fatality, serious or critical injury is immediately reported to Protection Services;
      16. Ensure, with the assistance of Protection Services, that the scene of an accident where a fatality, serious injury or critical injury has taken place is preserved such that there is no interference, disturbance, destruction, alteration or removal of anything at the scene until an investigation is conducted and the Office of the Chief Risk Officer indicates that the cleaning or moving of evidence from the scene is permitted;
      17. Ensure that Protection Services and/or a workplace first-aid responder are contacted immediately for assistance in providing first-aid to injured persons;
      18. Immediately investigate any work refusal in accordance with the internal procedure;
      19. Refer workers under their authority to the Human Rights Office if they become aware of allegations of harassment, including sexual harassment, discrimination and/or sexual violence and ensure that continued follow-up with the worker occurs in these circumstances;
      20. In the event a worker elects not to file a formal complaint to the Human Rights Office, ensure that allegations of harassment, including sexual harassment, discrimination and/or sexual violence from workers under their authority, are investigated, with the assistance of Human Resources or Labour Relations; 
      21. Ensure that there are means to summon assistance, that those means are in working order and accessible in University work spaces with increased risk due to: 
          • the presence or use of hazardous materials in quantities capable of causing injury 
          • the type of activity performed being at a level where there is a risk of injury 
          • a room being isolated from public areas 
          • there being limited access to a telephone
      22. Where they have hired an external contractor, require that the external contractor adhere to applicable health and safety legislation;
      23. Where they have engaged visitors or volunteers, monitor to ensure that such visitors or volunteers adhere to applicable health and safety legislation and University procedures and practices;
      24. Record their health and safety activities.

   9. WORKERS

      Workers are also responsible for health and safety in the performance of their duties. Workers will:

      1. Comply with the provisions of the applicable health and safety legislation and all health and safety procedures and practices that are made known to them;
      2. Use or wear equipment, protective devices or clothing as required by the University, and report to their supervisor the absence of, or any defect in, equipment or protective devices that may endanger themselves or other workers;
      3. Report all known health and safety hazards or any violation of the applicable health and safety legislation or University procedures to their supervisor;
      4. Not use or operate any equipment, machine, device, item or work method in a manner that endangers themselves or other workers;
      5. Not remove or make ineffective any protective device required by applicable health and safety legislation or by University procedure without providing an adequate temporary protective device; once the removal of the protective device is no longer required, the original protective device must be reinstalled immediately;
      6. Not engage in any prank, contest, feat of strength, unnecessary running, or rough and boisterous conduct, or otherwise endanger their co-workers or themselves;
      7. Report accidents and incidents to their supervisor, and complete and submit the University accident, incident, occupational illness or near miss form; 
      8. Attend and successfully complete mandatory and job-specific health and safety training sessions related to their work;
      9. Assist in reducing and controlling incidents and illnesses;
      10. Make their health and safety and that of others a personal goal. 
           

      Workers can refuse to work if there is reason to believe that their working conditions endanger themselves or another worker. Workers refusing to perform work must immediately advise their supervisor and follow the refusal to work procedure.

   10. STUDENTS

       Students are not workers and are not subject to the health and safety legislation applicable to workers; however, the University applies the principles of occupational health and safety legislation to students. Students are responsible for conducting themselves in a proper manner to ensure their own health and safety as well as that of others, and must adhere to university procedures and directives on health and safety. For greater clarity, students should refer to the duties listed under “workers.”

   11. CONTRACTORS

       Contractors must adhere to all applicable health and safety legislation governing their work and all contracts between the University and contractors must include a requirement that contractors (including any subcontractors) must do so.

   12. VISITORS AND VOLUNTEERS

       Visitors and volunteers might supply services to the University (though without monetary compensation) and are therefore subject to the same health and safety legislation applicable to workers. For greater clarity, visitors and volunteers are responsible for conducting themselves in a proper manner, consistent with that of workers, to ensure their own safety as well as that of others, and must adhere to University policies, procedures and directives on health and safety. Supervisors carry similar responsibilities for visitors and volunteers as they would for a worker.

   13. MULTI-SITE JOINT OCCUPATIONAL HEALTH AND SAFETY COMMITTEE

       The multi-site occupational health and safety committee structure is made up of the University Joint Occupational Health and Safety Committee (UJOHSC) as well as the Functional Occupational Health and Safety Committees, which are comprised of elected or appointed workers and nominated management representatives. The committee structure is regulated in accordance with the Occupational Health and Safety Act and the terms of reference.

       Members of the committees are responsible for, and have the power to:

       1. Conduct inspections of all University workspaces at least once yearly;
       2. Investigate and inspect a workplace where a fatality or a critical injury has occurred;
       3. Investigate a work refusal with the supervisor;
       4. Receive and review health and safety reports;
       5. Identify situations that may be a source of danger or hazard to workers;
       6. Make recommendations to the constructor or university and the workers to improve workers’ health and safety;
       7. Recommend to the University and the workers the establishment, maintenance and monitoring of programs, measures and procedures respecting the health or safety of workers;
       8. Obtain information from the University relating to potential or current hazards related to materials, processes or equipment, or relating to health and safety experience and work practices and standards in similar or other industries of which the University has knowledge;
       9. Obtain information from the University concerning the testing of any equipment, machine, device, article, thing, material or biological, chemical or physical agent in or about a workplace for the purpose of occupational health and safety;
       10. Be consulted about and have a designated member representing workers be present at the beginning of testing conducted in or about the workplace if the designated member believes their presence is required to ensure that valid testing procedures are used or to ensure that the test results are valid; 
       11. accompany an inspector of the Ministry of Labour, Training and Skills Development during the latter’s physical inspection of a workplace, or any part or parts thereof.

       For additional information on the structure of the multi-site committees, refer to the terms of reference.

4. IMPLEMENTATION

   The Office of the Chief Risk Officer is responsible for the development of this framework on behalf of the University. All members of the University community are responsible for implementing and applying the roles and responsibilities described here.

5. SHARED RESPONSIBILITY

   Notwithstanding the categories of personnel above, every member of the University community is responsible for ensuring a healthy and safe work environment.

6. EXCEPTION

   No exception or amendment may be made to this procedure without the approval of the Vice-President, Finance and Administration.

Revised September 26, 2022