Guidance

Information that has been published to date is posted; this includes all of the element audit checklists and select data forms.

Element Audit Checklists

The element audit checklists provide detailed criteria that are used by CAPP inspectors to determine compliance with each of the prevention program and emergency response program elements. Checklist I is completed by the CAPP inspector upon each compliance audit and is intended to cover various administrative issues and to facilitate follow-up to previous open inspection issues.

The remaining checklists are comprised of two parts: Procedure / Policy Review and On-Site Inspection – Records Audit. Under the Procedure / Policy Review, inspectors focus upon development of policies, procedures and programs associated with each of the program elements; including Management Plan and Document Control. Under the On-Site Inspection – Records Audit, inspectors focus upon implementation of the program element. Inspectors will look for evidence that the policies, procedures and programs are in place in the plant and that records are being maintained.

The checklists are intended to be comprehensive. CAPP inspectors do not review each checklist annually, but attempt to review each checklist at least once every five years, with two exceptions. Management of Change and Incident Investigation records are reviewed annually.

The element audit checklists include a “Percentage Completion Score;” providing the facility a semi-quantitative evaluation of their compliance status. Program Procedure and Program Implementation are scored separately.

The checklists also consider “Management Plan and Document Control”. The management plan includes both a management system and an implementation plan. The management system addresses the qualified persons who have responsibility for the development, implementation and integration for each element; including relevant lines of authority. The implementation plan addresses the who, what, when, where, and how for each of the elements. The implementation plan establishes how each element is implemented at the facility, ensuring program continuity in the event of personnel changes. The implementation plan also includes how information and documentation is controlled and ensures that the most current information and documents are in use. Some of the checklists address these requirements in the “Management Plan and Document Control” section, while others have these requirements interspersed in each section of the checklist.

Data Forms

The audit data forms are used by CAPP inspectors to help structure various program data, thus facilitating review. Frequently, the inspectors ask the facility to complete these forms in advance of an inspection. The data forms also include a discussion of compliance topics, including examples in some cases.