INTEGRATED

TITLE
ASSURANCE CATEGORY
FUNCTIONAL CHECKLIST
MANAGEMENT SYSTEM (MS)
RELATED INTERNAL GOVERNING, EXTERNAL OR REGULATORY DOCUMENTS (IF APPLICABLE)
RECOMMENDED ASSESSOR (ROLE)
MANDATORY ATTACHMENT
* Mandatory Fields
bdced65c-d70d-4166-bf28-a657d2ce8fc1

NO Checklist

1.0 Health Surveillance

Medical Surveillance has been conducted for workers (Employee and Contractors) identified
via HRA and/or exposure monitoring for Hazardous Chemical.
1.1
Evidence: Verify list of workers who has undergone Medical Surveillance as planned.

Medical Surveillance has been conducted for workers (Employee and Contractors) identified
via HRA and/or exposure monitoring for Noise.
1.2
Evidence: Verify list of workers who has undergone Medical Surveillance as planned.
 Medical Surveillance has been conducted for workers (Employee and Contractors) identified
via HRA and/or as per legal requirement for Radioactive Material .
1.3
Evidence: Verify list of workers who has undergone Medical Surveillance as planned.

All pregnant employee working with hazardous chemical has notified her respective
supervisor of Human Resource personnel using pregnancy declaration form as spon as
possible.
1.4
Evidence: Verify that every pregnant employee has submitted Pregnancy Declaration Form
to her respective supervisor of Human Resource personnel

Confirmed pregnant and/or breastfeeding employees are medically removed from working
in hazardous chemical area.
1.5
Evidence: Verify Medical Removal Protection (MRP) Records as per above situation.

2.0 Return to Work (RTW)

All employees who were under temporary MRP have undergone Medical Assessment before
returning to Work.
2.1
Evidence: Verify RTW Medical Assessment for employee under temporary MRP

3.0 Performance Monitoring and Reporting

Positive Medical Surveillance is reported to respective BUs/OPUs and relevant Authority

3.1 Evidence : Verify proof of submission for positive Medical Surveillance to respective
BUs/OPUs and relevant Authority

4.0 Incident Notification, Investigation and Reporting

 All cases of positive results from Medical Surveillance were investigated and appropriate
corrective actions plan been approved
4.1
Evidence : Verify investigation and corrective action plan has been approved by BUs/OPUs
Management

5.0 Health Surveillance Records

Health Surveillance records are kept confidential and stored in a secure filing and/or may be
archived in electronic data management system.
5.1
Evidence : Verify Health Surveillance records are being kept in secure manner.

Percentage Compliance
= Total Complied(Y) / Total Questionnaires(Y+N)
INTEGRATED ASSURANCE
Functional Assessment
HSE
Health Surveillance [M]
HSE Management System (H

No

Compliance

Yes
Vigilancia de la salud

Se ha llevado a cabo la vigilancia médica de los trabajadores (empleados y contratistas)

identificados mediante HRA y/o monitorización de la exposición a sustancias químicas
peligrosas.

Pruebas: Verificar la lista de trabajadores que han sido sometidos a Vigilancia Médica según
lo planificado.

Se ha llevado a cabo la Vigilancia Médica de los trabajadores (Empleados y Contratistas)

identificados mediante HRA y/o monitorización de la exposición al Ruido.

Evidencia: Verificar el listado de trabajadores que han sido sometidos a Vigilancia Médica
según lo planificado.
Se ha llevado a cabo la vigilancia médica de los trabajadores (empleados y contratistas)
identificados mediante HRA y/o según los requisitos legales para el material radiactivo.
Evidencia: Verificar la lista de trabajadores que se han sometido a vigilancia médica según lo
previsto.

Todas las empleadas embarazadas que trabajan con productos químicos peligrosos lo han
notificado a sus respectivos supervisores o al personal de Recursos Humanos utilizando el
formulario de declaración de embarazo lo antes posible.

Evidencia: Verificar que todas las empleadas embarazadas han presentado el Formulario de
Declaración de Embarazo a su respectivo supervisor del personal de Recursos Humanos.

Se confirma que las empleadas embarazadas y/o en periodo de lactancia son retiradas
médicamente del trabajo en el área de productos químicos peligrosos.

Pruebas: Verificar los Registros de Protección Médica de Retiro (MRP) de acuerdo a la

situación anterior.

Vuelta al trabajo (RTW)

Todos los empleados que estaban bajo MRP temporal han sido sometidos a una Evaluación
Médica antes de volver al Trabajo.

Pruebas: Verificar la Evaluación Médica RTW para el empleado bajo MRP temporal.

Supervisión del rendimiento y elaboración de informes

Los resultados positivos de la Vigilancia Médica se comunican a las respectivas BUs/OPUs y a

la Autoridad competente.

Prueba : Verificar la prueba de la presentación de un informe positivo de Vigilancia Médica a

las respectivas BUs/OPUs y a la Autoridad pertinente.

Notificación, investigación y notificación de incidentes

Todos los casos de resultados positivos de la Vigilancia Médica fueron investigados y se
aprobó el plan de acciones correctivas apropiado

Prueba : Verificación de que la investigación y el plan de medidas correctivas han sido

aprobados por la dirección de las unidades de negocio/unidades operativas.

Registros de vigilancia sanitaria

Los registros de Vigilancia de la Salud se mantienen confidenciales y se guardan en un

archivo seguro y/o se pueden archivar en un sistema electrónico de gestión de datos.

Prueba : Compruebe que los registros de Vigilancia de la Salud se guardan de forma segura.

%
Functional Assessment REVISION MODIFIED DATE
HSE GOVERNANCE PROVIDER
Health Surveillance [M] MANDATORY/RISK-BASED
HSE Management System (HSE MS) MINIMUM FREQUENCY (IF MANDATORY)
FOCAL PERSON / SME
APPLICABILITY
No

Compliance
Remark MS Element MS Sub-Element

No N/A
%
13 January 2022
Group Health, Safety & Environment (GHSE)
Risk-Based

OTHER ASSURANCE CATEGORY MAPPING

(Please specify other Assurance Category for
system mapping purpose - Refer
AssuranceCategory sheet) OTHER ASSURANCE Section Weightage
CATEGORY MAPPING
(Please specify other assurance aategory for
system mapping purpose - Refer Table 1 below)

HSE

HSE
HSE

HSE

HSE

HSE

HSE
HSE

HSE
Country
Exploration
Finance - Financial Reporting Control
Finance - Tax
Finance - Treasury
Financial
First Line Assurance
HSE
Human Resource
ICT
Integrity
Legal & Regulatory
Marketing and Sales
Other – Commercial
Other – LPG
Other – Retail
Other – Supply & Distribution
Others
PETRONAS Resiliency Model (PRM)
Plant & Facilities
Procurement
Project
Reputation
Risk Management
Security
Sustainable Development
Technology
Assurance
Hazards and Effects Management Process
Implementation and Monitoring
Leadership and Commitment
Management Review
Organisation, Reponsibilities, Resources, Standards and Documents
Planning and Procedures
Policy and Strategic Objectives
Accountability & Informed Involvement
Assessment
Assessor Competency
Asset Integrity and Reliability
Assurance Plan
Communication
Competence
Content
Contractor Assurances
Contractor HSE Management
Control Measures
Dissemination
Documentation and Controls
Drive HSE Culture
Emergency Preparedness and Response/ Crisis Management Requirements
HSE Advisors/ Management Representative (MR)
HSE Plan
HSE Programmes and Activities
Identification of Hazards and Effects
Incident Reporting and Follow Up
Legal and Other Governing Bodies' Requirements
Management of Change
Management Review
Non-compliance, Corrective and Preventive Action
Performance Monitoring
Proactive in Managing HSE Risk
Procedures and Work Instruction
Records
Recovery Measures
Resources
Roles and Responsibilities (Organisation Structure and Responsibilities)
Statutory HSE Risk Assessment Requirement
Strategic HSE Objectives
Visible HSE Leadership