Internal Audit Protocol

1. The purpose of our protocol

Our protocol sets out the responsibilities and actions which are required for the establishment of the University Wellbeing and Safety (W&S) internal audit program, which forms part of the University’s operational (second line) assurance activities.

This protocol should be read in conjunction with the Wellbeing and Safety System Management and Review Procedure which gives effect to the Wellbeing and Safety Policy.

2. Our protocol applies to

2.1 Inclusions

All W&S activities under the W&S policy/procedures/protocols and members of our Adelaide University Community.

2.2 Exclusions

Knowledge articles associated with the W&S protocols.
Any audits not conducted by W&S team including the University's Internal Audit Program (e.g. managed by Risk Services)

3. Our W&S internal audit protocols

3.1 Roles and responsibilities

University roles and responsibilities for managing wellbeing and safety monitoring and reviewing safety objectives, including W&S internal audits, are set out in the Wellbeing and Safety System Management and Review Procedure.

3.2 Ensuring W&S internal audit management

The table below outlines key roles and responsibilities for end to end W&S internal audit management.

Role	Responsibilities	Protocols
People Leaders /Supervisors	Must: Assist Wellbeing and Safety (W&S) to ensure that W&S internal audits are compliant and effective	Ensure active participation in W&S internal audits that are carried out within your area of responsibility. Consult with W&S regarding suitable actions to correct any findings or observations. Ensure that, in consultation with workers, immediate action is taken to address any significant non-conformance or non-compliance identified, where there is real potential for university breach of legislation and/or risk of serious personal injury or fatality. Ensure all corrective actions are documented in Unisafe. Ensure that all corrective actions are completed within the allocated agreed timeframe. Ensure that W&S audit results are used in local area W&S planning (ie. Local Action Plans, W&S Operational Plans).
Director Wellbeing and Safety	Must: ensure that W&S internal audits are compliant and effective	Nominate a trained person within Wellbeing & Safety team to act as W&S lead auditor/s. Approve the W&S audit plan. Ensure that the W&S audit plan and results are contained in the governance report for People, Culture and University Community Safety Committee, the University Risk Management Committee and Council.
Senior Manager W&S Governance	Must: ensure that W&S internal audits are compliant and effective	Management Ensure that the audit program is designed and managed in accordance with the W&S internal audit principles set out in Appendix A and B. Planning Ensure that the audit team have completed an accredited auditing course and have a Statement of Attainment (or equivalent competency). In consultation with W&S senior managers determine which topics and locations will be audited (based on W&S Procedures/Protocols) based on (but not limited to): emerging hazards and issues (refer to Unisafe and committee minutes) overarching consolidated audit results and performance findings. hazard profile and rating recommendations from colleges/portfolios injury data. Using the principles outlined in Appendix B, construct a W&S internal audit schedule and ensure it is made available on the staff portal. Measurement and Evaluation In consultation with lead auditor/s create a summary audit document for each audit round to be review at People, Culture and University Community Safety Committee, the University Risk Management Committee and Council. Improvement strategies Analyse the W&S audit findings and performance measures; and consolidate them into the overarching file Ensure that these results are used in W&S planning (ie. Local Action Plans, W&S Strategic and Operational Plans) the next W&S internal audit round and changes to policy/procedure/protocol documents.
W&S lead auditor/s	Must: ensure that W&S internal audits are compliant and effective	Planning Participate in the construction of the W&S internal audit schedule. Implementation In consultation with the W&S auditors, develop question sets based on the actions required within the W&S procedures/protocols, performance measures and other legislative requirements, where applicable. determine the format of the audit (desk top or traditional – document review, inspection and interviews) and what evidence is required to be viewed by the W&S auditors. Communicate with the People Leaders/ Supervisors of the location, Dean of School/ Director of sub-functions, Health and Safety Representative (HSR if applicable) of the workgroup and W&S Senior Advisor. W&S audit finding disputes In consultation with the W&S auditor and/or the supervisor obtain a summary of the dispute together with any objective evidence provided by the auditee and make changes to the outcome where relevant. Measurement and Evaluation Conduct quality control over the audit findings, then send the report to the Executive of College/Portfolio, Dean of School/ Director of sub-functions, the supervisors audited and relevant HSRs, outlining the results and the deficiencies. Ensure that the audit actions address the issues found and close the audit once all actions are assigned.
W&S auditors	Must: ensure that W&S internal audits are compliant and effective	Planning In consultation with the W&S lead auditor/s develop question sets based on the actions required within the W&S procedures/protocols, performance measures and other legislative requirements, where applicable. Upload the questions to Unisafe. Determine the evidence required to be viewed by the W&S auditors. Implementation Conduct a pre-audit meeting with the supervisor to discuss which of the following elements will be applied (depending on the audit questions): documentation to be supplied an inspection of the audit area formal interviews. Schedule and conduct the audit at a mutually agreeable time with the supervisor. Note: Where a supervisor does not comply with reasonable requests to complete the audit within the audit cycle then the matter is to be referred to the Director, W&S. Measurement and Evaluation Capture the outcomes from the audit in Unisafe. Ensure that actions address the findings. Report to the supervisor the following: conformance (including good practise findings) non-conformance opportunities for improvement out-of-scope findings. Conduct a closing meeting with the Executive and provide the supervisor opportunity to comment on the above. Compile a draft final report, arrange for W&S lead auditor and/or another W&S auditor to conduct quality control over the audit findings, then send the report to the Executive of College/Portfolio, Dean of School/Function, the supervisors audited and relevant HSRs, outlining the results and the deficiencies. Provide advice to the supervisor regarding appropriate corrective actions, reasonable timeframes and person responsible for the action(s). Ensure corrective actions in Unisafe are completed. Ensure that evidence is attached to all actions before closing. Inform your manager of the results so they can be reported to the relevant College/Portfolio Executive and safety committees.

4. Performance Measures

W&S audit program conforms with this protocol.
All W&S audits completed as per the audit plan.
All agreed actions to address non-conformances or non-compliance have been completed within the agreed timeframes.
All agreed actions to address opportunities for improvement have been completed within the agreed timeframes.
W&S audit performance can demonstrate continuous improvement.

5. Definitions used in our protocol

Conformance (C) – means that evidence obtained verifies activities undertaken and results achieved fulfil the specified requirements of the system elements.

Health and Safety Representative –means a person who has been elected by a workgroup to represent them to management on WHS issues. They act in a voluntary capacity representing their workgroup and have specific roles and functions under the WHS Act and Regulations which may be utilised where there are safety concerns.

W&S Internal Audit - means a systematic and independent assessment of W&S activities against defined criteria to confirm they are implemented effectively and achieve organisational objectives. Which are conducted to

assess performance against policies, plans, and objectives
ensure corrective actions are implemented and good practices are shared
support management review and continuous improvement of systems and strategies.

Legal Compliance – means management to comply with an Act, any Regulations or determinations made under an Act or a term of condition of registration or licensing.

Non-conformance (NC) means that verified evidence shows activities and results do not meet system requirements; corrective actions must be prioritised and implemented based on risk to ensure safety and legal compliance.

Opportunity for Improvement (OFI) means that evidence obtained verifies a fulfilment of a specified system requirement however an opportunity for improvement exists due to minor deficiencies.

Out of Scope Findings (OSF) - means that evidence identified beyond the audit scope showing results do not meet system requirements; corrective actions must be prioritised and implemented based on risk to ensure safety and legal compliance.

Safety Management System – the part of the overall management system which includes organisational structure, planning activities, responsibilities, practices, procedures and resources for developing, implementing, achieving and reviewing the W&S policy and so managing the risks associated with the business of the University.

Supervisor – for the purposes of this protocol means the supervisor of the location being audited.

System Element – a significant, indispensable element of the safety management system (for example: hazard management, training, consultation, emergency management).

6. How our protocol is governed

6.1 Compliance

W&S Internal Audit management at Adelaide University is conducted in compliance with the following established regulations and guidelines:

Legislation & Code of Practice

6.2 Governance

This protocol is categorised, approved and owned in line with the governance structure of Adelaide University and the offices and officers listed below.

Parent procedure	Authority to create and maintain this protocol is granted under the Wellbeing and Safety System Management and Review Procedure
Policy category	Corporate
Approving authority	Executive Director, People Advisory and Wellbeing
Policy owner	Deputy Vice Chancellor People and Culture
Responsible manager	Deputy Vice Chancellor People and Culture or their delegate
Effective from	1 October 2026
Review date	1 October 2031
Enquiries	Wellbeing and Safety Team
Replaced documents	None

7. History of changes

Date approved	To section/clauses	Description of change
1 Oct 2026	N/A	New protocol

Appendix A

W&S Internal Audit Principles

The AU W&S Internal audit program objectives are to be:

System-Focused Analysis: Audits will extend beyond identifying physical hazards to evaluating the effectiveness of management systems, including leadership commitment, training effectiveness, and risk control measures.
Proactive Risk Mitigation: The program will identify potential vulnerabilities, such as gaps in procedures or safety culture, before incidents occur, supporting preventative action.
Risk-Based Approach: Audit activities will be prioritised based on risk to ensure focus on areas of highest impact.
Consistency and Standardisation:Audit methods, criteria, and processes will be applied consistently across all operations to ensure reliability, comparability, and repeatability.
Compliance and Alignment:Audits will align with applicable legislation, regulatory requirements, ISO standards, and AU policies, procedures and protocols.
Independent Evaluation: W&S Audits will be conducted by qualified W&S auditor and where practicable, they will be independent of the activities they are auditing ie not auditing work for which they are directly responsible.
Stakeholder Engagement: Relevant stakeholders will be consulted and informed throughout the audit process to enhance cooperation, understanding, and audit effectiveness.
Evidence-Based Assessment: Findings will be supported by verifiable and documented evidence.
Transparency and Accountability: Audit outcomes will be clearly communicated, with defined responsibilities, corrective actions, and timeframes to ensure accountability.
Digital Integration: Audits will use Unisafe for documentation, reporting and corrective actions to make the auditing process faster, more accurate, and easier to analyse.
Fair Presentation: Audit findings, conclusions, and reports will reflect truthfully and accurately the audit activities undertaken. Significant obstacles, differing opinions, and unresolved issues will be transparently reported.
Continuous Improvement:Audits will form part of an ongoing improvement cycle, embedded within W&S management system to monitor, review, and enhance system performance and outcomes.

Appendix B

Managing the W&S Internal Audit Program

Plan	The W&S internal audit plan will have two elements A 3-year fundamental audit plan covering topics which form the basic foundations of the W&S Management system covering off on selected areas of the business (not covered by the supplementary audits). Supplementary audits will be designed at least 1 month in advance to keep the audits nimble and relevant. These will be based on: safety issues raised in Unisafe emerging hazards and issues overarching Local Action Plan, consolidated audit results and performance findings. recommendations from senior management or the University people and culture committee. the following coverage measures: % of Colleges, Schools, Functions and Sub-Functions / processes audited coverage of critical systems and high-risk areas frequency of audits in line with risk-based schedule.
Selection of Location	Workplaces may be selected at randomly selected or targeted based on annual Local Action Plan performance, data analysis, previous evaluation findings and/or a focus on regulatory requirements.
Scope	The scope will be determined by the W&S lead auditor and the supplementary W&S audits’ scope will be based on high-risk activities over low risk (administrative) activities. Whilst undertaking the audit if the W&S auditor sees non-compliance findings they can be recorded as out of scope findings. Which will not impact the audit score for the in-scope topics.
Conducting	Individual workplaces selected for audit will be contacted in advance. HSRs will be invited (if applicable). The scope will be known in advance. The audit will (generally) consist of walk through, interviews and document review. Documents will be collected to support outcomes of the audit Outcomes will be communicated with the area before the audit is finalised.
Reporting	The finalised audit report will be sent to the areas management, auditee and HSR (if applicable). Corrective actions will be identified with the supervisor of the area, with the person responsible and due date. Corrective actions will be monitored by W&S advisory, the Dean and the local safety forums.
Trends and Improvement	A summary report outlining all audit findings, trends and opportunities to improve system elements will be issued to Director of W&S and included in governance and consultative committees. Recommended system improvements are incorporated into the respective program/procedural review process.