QUALITY PROCEDURES MANUAL - USeP€¦ · c. Controlled copies issued to named individuals found in the Distribution List (FM-USeP-COD- uncontrolled copy 04) are stamped …

Republic of the Philippines

University of Southeastern PhilippinesF. Iñigo St., Bo. Obrero, Davao City 8000, Philippines

Telefax: (082) 221-7737; 227-5524Trunkline: (082) 224-4480; 227-8192

www.usep.edu.ph; [email protected]

ISO 9001:2008QUALITY MANAGEMENT SYSTEM

COPY HOLDER: DCOISSUE STATUS: 01

MANUAL EFFECTIVITY: 10 OCTOBER 2016

This Manual is property of USeP.Reproduction in part or in whole is strictly prohibited and should not be brought out of the

Organization’s premises without prior consent or approval from the President.

MASTER COPY

QUALITY PROCEDURESMANUAL

UNCONTROLLED C

OPY

PRINTING AND REPRODUCTION IS NOT ALLOWED

MASTER COPY

University of Southeastern

Philippines (USeP) F. Inigo Street, Obrero, Davao City 8000, Philippines

Telefax: (082) 221-7737; 227-5524

Trunkline: (082) 2244480; 2278192 www.usep.edu.ph ; email: [email protected]

Document No. PM-USeP-TOC

Issue Status 01

Revision No. 00

Date Effective 10 October 2016

Page No. 1 of 2

PROCEDURES MANUAL

MASTER COPY

Prepared by: Approved by:

_________________________________

LOURDES C. GENERALAO, Ph.D

President

_________________________________

ARISTEO C. SALAPA

QMR

TABLE OF CONTENTS

DOCUMENT NO. DOCUMENT TITLE ISSUE

STATUS

REV.

NO.

DATE EFFECTIVE NO. OF

PAGES

PM-USeP-TOC Table of Contents 01 00 10 October 2016 2

PM-USeP-COD Control of Documents 01 00 10 October 2016 9

PM-USeP-COR Control of Records 01 00 10 October 2016 7

PM-USeP-CER Control of External References 01 00 10 October 2016 3

PM-USeP-IQA Internal Quality Audit 01 00 10 October 2016 15

PM-USeP-HNC Handling of Non-conformance 01 00 10 October 2016 5

PM-USeP-CAR Corrective Action 01 00 10 October 2016 3

PM-USeP-PAR Preventive Action 01 00 10 October 2016 3

PM-USeP-OTS Objectives and Target Setting 01 00 10 October 2016 4

PM-USeP-CMR Conduct of Management Review 01 00 10 October 2016 4

PM-USeP-HCF Handling of Client’s Feedback 01 00 10 October 2016 8

PM-USeP-CMI Classroom Management Instruction 01 00 10 October 2016 3

PM-USeP-PIM Preparation of Instructional Materials 01 00 10 October 2016 3

PM-USeP-PPE Preparation of Periodic Examinations 01 00 10 October 2016 5

PM-USeP-PRC Preparation/Revision of Curriculum 01 00 10 October 2016 9

PM-USeP-PRS Preparation/Revision of Syllabus 01 00 10 October 2016 7

PM-USeP-CRP Conduct of Research Programs 01 00 10 October 2016 17

PM-USeP-CEP Conduct of Extension Programs 01 00 10 October 2016 11

PM-USeP-EOS Enrolment of Students 01 00 10 October 2016 2

PM-USeP-ANS Admission of New Students 01 00 10 October 2016 3

UNCONTROLLED C

OPY


mailto:[email protected]

MASTER COPY



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-TOC

Issue Status 01

Revision No. 00


Page No. 2 of 2

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

DOCUMENT NO. DOCUMENT TITLE ISSUE

STATUS

REV.

NO.

DATE EFFECTIVE NO. OF

PAGES

PM-USeP-RSC Request for Student Credentials 01 00 10 October 2016 6

PM-USeP-HSC Handling of Student Complaints 01 00 10 October 2016 3

PM-USeP-RSO Reaccreditation of Student

Organization

01 00 10 October 2016 3

PM-USeP-SEP Student Employment Process 01 00 10 October 2016 3

PM-USeP-FES Faculty Evaluation by Students 01 00 10 October 2016 3

PM-USeP-HSE Hiring and Selection of Employees 01 00 10 October 2016 6

PM-USeP-EPE Employees Performance Evaluation 01 00 10 October 2016 11

PM-USeP-TDE Training and Development of

Employees

01 00 10 October 2016 11

PM-USeP-ARS Admission and Renewal of Scholarship/

Grants

01 00 10 October 2016 7

PM-USeP-RGC Referral for Guidance and Counseling 01 00 10 October 2016 6

PM-USeP-PMS Preventive Maintenance Schedule 01 00 10 October 2016 3

PM-USeP-HOR Handling of Repairs 01 00 10 October 2016 4

PM-USeP-PUR Purchasing 01 00 10 October 2016 13

PM-USeP-IAI Inspection and Acceptance of Items 01 00 10 October 2016 7

PM-USeP-SOA Supplier and Outsource Accreditation 01 00 10 October 2016 5

PM-USeP-SMC Student Medical Consultation 01 00 10 October 2016 6

PM-USeP-IMC Issuance of Medical Certificate 01 00 10 October 2016 3

PM-USeP-AVR Audio-Visual Room Reservation 01 00 10 October 2016 4

PM-USeP-BBT Book Borrowing Transaction 01 00 10 October 2016 7

PM-USeP-LRA Library Resources Acquisition 01 00 10 October 2016 7

UNCONTROLLED C

OPY



MASTER COPY

TITLE CONTROL OF DOCUMENTS

PURPOSE/S

To ensure that all documents are accurately recognized, rationalized, can be

retraced and approved before issued as references in the implementation of

the excellence management system.

SCOPE This procedure covers control of all internal documents used as references.

Control of external references is covered in PM-USeP-CER.

TERMS AND

DEFINITIONS Controlled Document - refers to any issued document which has been

uniquely identified for ease of traceability and recall. Such document cannot

be reproduced in any circumstances.

DCO - refers to Document Control Officer who handles documents and serves

as records controller of the organization.

Process / Activities Responsible Office /

Person/s

Details /

Reference

Concerned Office/Personnel Note 1


Concerned Office/Personnel


QMR Note 4

Prepare Document Change Request Record

Identify the need for New/Revise/Change Document

Amend Existing Document

Yes

No

New Document? Draft New Document

Review New/Revised/Changed Document

B

A



Telefax: (082) 221-7737; 227-5524

Trunkline: (082)2244480; 2278192 www.usep.edu.ph ; email: [email protected]

Document No. PM-USeP-COD

Issue Status 01

Revision No. 00


Page No. 1 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

Process / Activities Responsible Office /

Person/s

Details /

Reference

President / QMR


DCO Note 6

DCO Note 7

QMR / Assigned Personnel Note 8

Update Document Master List

Finalize New/Revised/Changed Document

Issue New/Revised/Changed Document

Orient concerned personnel

Yes

Approved? B

No

A

NOTE 1:

1. All documents and data that are related to the implementation of the established Quality

Management System shall be controlled, reviewed and authorized by the QMR for adequacy

prior to issue and use.

2. The concerned office/personnel of the new/revise/change document discusses with the QMR

the proposed new/revise/change document to determine whether or not it is relevant to the

Quality System.

3. Documents may be required as a result of corrective action, preventive/improvement action,

or approval of new processes. Documents may also be deleted if found unnecessary anymore

in the implementation of the QMS.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 2:

1. If the document is found to be relevant, the QMR issues the Document Change Request (DCR)

using FM-USeP-COD-02 Form to the concerned office/personnel who shall fill it up with

appropriate information needed and affix signatures.

NOTE 3:

1. The concerned office/personnel returns the filled-up Document Change Request (FM-USeP-

COD-02) attached with a clean draft copy of the amended new/revised/changed document

to the QMR.

2. The QMR recommends the inclusion of the form to the QMS by affixing his/her signature and

submit the Document Change Request (FM-USeP-COD-02) and draft of the new/revised/

changed document to the Document Control Officer (DCO) for the assigned DCR No. and

discusses the necessity of the form.

NOTE 4:

1. Upon reviewing document, if the QMR finds the document relevant to the QMS, the DCR Form

will be submitted to the President for approval.

2. Upon approval, the QMR approves the reproduction and forwards the same to the DCO.

NOTE 5:

1. Quality Manual and Procedures Manual

a. All pages of the manuals have a header containing the following information:

- Organization’s name and address

- Manual name

- Document No.

- Issue Status

- Revision number

- Date Effective

- Page number (in the format # of # per section)

b. A footer identifying the authorized persons who prepared and approved the manuals.

c. Controlled copies issued to named individuals found in the Distribution List (FM-USeP-COD-

04) are stamped with “CONTROLLED COPY” at the front of all pages.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 4 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

d. Master copy of documents is identified by a “MASTER COPY” stamped at the front of each

page.

2. Documents in the Quality Policy Manual and Procedures Manual including the Forms are

assigned with a unique number for proper identification.

3. Unique numbering of the established manuals are as follows:

4. Documents become effective upon approval.

NOTE 6:

1. For changes in the Quality Policy and Procedures Manuals, the Document Master List (FM-

USeP-COD-01) and the Document Change Register (FM-USeP-COD-03) shall be updated.

2. The DCO shall indicate in the document the revision status and effectivity date of the change

(s) in the document.

3. For revised/changed document, the Master and Controlled Copies of the obsolete

documents are stamped with “OBSOLETE”. Only the obsolete Master copy is retained for

reference throughout the life of the quality system. Obsolete Controlled copies may be

recycled or reuse.

4. The DCO will collect the controlled copies from the process owners and update the

Distribution List to ensure its adequacy prior to its use.

NOTE 7:

1. New/Revisions/Changes of the manuals must be recorded. The recipient signs on the updated

Distribution List (FM-USeP-COD-04) to ensure that all copy holders are given the new/revised/

changed document.

2. In case of loss of issued copies, the copyholder prepares a CPAR and declares the copy as

Quality

Policy

Name of

Organization

Title Abbreviation

QP-USeP-TOC PM-USeP-COD

Procedures

Manual

Name of

Organization

Process Abbreviation

Sequence

FM-USeP-COD-01

Form Name of

Organization

Process Abbreviation

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 5 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

lost; document controller updates the Distribution List.

3. Review of documents is conducted by the DCO and QMR once every year or as deemed

necessary to verify whether there are documents that need to be revised/updated/abolished.

4. Manuals may be re-issued by the DCO as approved by the President or QMR. Only the Master

Copy will be reproduced.

NOTE 8:

1. The QMR/Assigned Personnel orients on the new/revised/changed documents for proper

implementation of the documented system.

2. Holders of controlled documents shall be responsible for the storage and protection of these

documents to prevent loss and damage.

RECORDS GENERATED:

Document Master List FM-USeP-COD-01

Document Change Request FM-USeP-COD-02

Document Change Register FM-USeP-COD-03

Distribution List FM-USeP-COD-04

FORM/S:

Document Master List FM-USeP-COD-01

Document Change Request FM-USeP-COD-02

Document Change Register FM-USeP-COD-03

Distribution List FM-USeP-COD-04

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 6 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 7 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 8 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 9 of 9

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY

TITLE CONTROL OF RECORDS

PURPOSE/S

To ensure that all proceedings produced during the implementation of the

excellence management system are properly recognized, stored and secured

to avoid mislay of records.

To ensure that the custodian checked the records well and these are up to

date, if the time retention has lapsed.

To ensure compliance to the rules and regulations prescribed under the

Republic Act 9470 or the National Archives of the Philippines (NAP) Act of 2007.

To ensure compliance with the guidelines set in the established records

management policy. SCOPE

This procedure covers all essential records control.

TERMS AND

DEFINITIONS Record - a document stating results achieved to provide evidence of activities

performed.

Record Disposition - the orderly maintenance of records necessary to protect

the interest of economy and efficiency, the prompt disposal of valueless

records.

Process / Activities Responsible Office/

Person/s

Details /

Reference


Concerned Personnel Note 2

DCO Note 3


DCO Note 5



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-COR

Issue Status 01

Revision No. 00


Page No. 1 of 7

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

File Records generated

Generate required Records

Monitor retention periods of filed Records

Dispose Obsolete Records

Monitor filing

Yes

Lapsed? No

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 7

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 1:

1. Generate all records required in the procedures.

2. Records are documents/data which furnish objective evidence of activities performed or

results achieved in the implementation of the Quality Management System or evidence of

conformity to any statutory and regulatory requirement.

2. Ensure all required data in forms used are completely filled-out including portions that require

signatures.

3. Client provided records such as personal data are considered customer property and are

covered in Control of External References procedure (PM-USeP-CER).

NOTE 2:

1. Records shall remain legible, readily identifiable and retrievable.

2. The identification of storage, retention time, disposal and custodian of records, are indicated

in the Masterlist of Records (FM-USeP-COR-01).

3. Records received through fax would have to be photocopied and then filed.

4. Incoming and outgoing communications shall be properly recorded and disseminated in

accordance to the Communication Flow maintained and established in each campus.

5. Each office shall keep Records in filing/storage cabinets properly labelled to ensure easy

identification of the locations of files.

6. Electronic data, back up files shall be saved in external hard drives and shall be maintained

to protect records from fire and other similar calamities.

7. Refer the Work Instructions Manual for the Records Management System.

NOTE 3:

1. It is the concern of the university personnel to exercise control of records as required in their

respective duties and responsibilities.

2. Externally generated documents shall be recorded in the Masterlist of External Reference (FM

-USeP-COR-01) and updated from time to time.

3. Superseded documents like circulars, guidelines memoranda, etc. shall be removed and

marked “obsolete” to preclude use. A copy may be retained for reference purposes marked

as “obsolete”.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 7

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 4:

1. Refer to Records Management Policy for the disposal of records.

2. Non-confidential records can be recycled but ensure that the wrong side would have to be

crossed once or stamped with “OBSOLETE” to avoid confusion.

NOTE 5:

1. Monitor filing of all records based on the Masterlist of Records (FM-USeP-COR-01).

2. The document controller also files a copy of all the DCO’s Masterlist of Records (FM-USeP-

COR-01) to serve as back up, but updating of the Masterlist of Records is done by the

individual DCO every Department.

3. Changes in records are initialed by authorized personnel.

4. Records may be reproduced when required as approved by the President or the QMR.

5. Review Masterlist of Records (FM-USeP-COR-01) at least once a year.

RECORDS GENERATED:

Masterlist of Records FM-USeP-COR-01

Incoming/Outgoing Correspondence Register

(previously Form No. 2-A) FM-USeP-COR-02

Incoming Courier and Postal Mail Register

(previously Form No. 2-B) FM-USeP-COR-03

Mail Forwarding Service Register

(previously Form No. 2-C) FM-USeP-COR-04

FORM/S:

Masterlist of Records FM-USeP-COR-01

Incoming/Outgoing Correspondence Register FM-USeP-COR-02

Incoming Courier and Postal Mail Register FM-USeP-COR-03

Mail Forwarding Service Register FM-USeP-COR-04

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 4 of 7

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 5 of 7

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 6 of 7

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 7 of 7

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY

TITLE CONTROL OF EXTERNAL REFERENCES

PURPOSE/S To ensure that all external references used in the implementation of the quality

management system are accurately acknowledged, protected and efficient.

SCOPE This procedure covers control of all external references such as policies and

memoranda, machine manuals, copies of regulatory requirements and other

documents of external origin that are relevant to the operations of the

organization excluding Client’s property and the references in the Library,

which shall be controlled under the Registrar’s Office policy and Library

process, respectively. TERMS AND

DEFINITION/S External Reference - refers to documents of external origin determined by the

organization to be necessary for the planning and operation of the quality

management system.


Person/s

Details /

Reference


DCO Note 2

DCO Note 3

DCO Note 4

Compile Master List of External References

Identify External References

Log Borrowed References

Identify New Issues and Update Master List



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-CER

Issue Status 01

Revision No. 00


Page No. 1 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 1:

1. Identify external references used in the implementation of the quality management system.

Prepare Masterlist of External References (FM-USeP-CER-01).

2. Masterlist of External References can be generated from different institution/offices received

in Obrero campus.

NOTE 2:

1. Compile all Masterlist of External References (FM-USeP-CER-01).

2. Stamp cover page of external references with “CONTROLLED COPY” before filing or issuance.

3. Books, Manuals or other references that are personally owned by the Professor are excluded

in the masterlist.

NOTE 3:

1. Use the External Reference Logbook to monitor the borrowing and returning of references.

2. The External Reference Logbook records the following data:

- Date Borrowed - Title of External Reference - Borrower

- Borrower’s Signature - Date Returned - Remarks

NOTE 4:

1. Identify new issues or updates of external references.

2. Update the Masterlist of External References (FM-USeP-CER-01).

3. Review of the Masterlist of External References (FM-USeP-CER-01) is done every year.

RECORDS GENERATED:

Master List of External References FM-USeP-CER-01

FORM/S:

Master List of External References FM-USeP-CER-01

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY

TITLE INTERNAL QUALITY AUDIT

PURPOSE/S

To establish and maintain a documented procedure for the conduct of internal

quality audits in order to:

determine whether the Quality Management System (QMS) conforms to the

planned arrangements, to the requirements of ISO 9001: 2008 and to the

specified requirements of NMIT documented QMS.

verify the implementation and effectiveness of the QMS in meeting specified

quality objectives.

provide the auditee with an opportunity to improve the quality system and

consistently meet the regulatory requirements.

SCOPE This procedure shall cover all the elements and processes of the Quality

Management System in all levels. This starts with the preparation of an Annual

Audit Plan, planning the actual conduct of the audit, audit proper, reporting

the results of the audit, verifying the actions taken to correct / prevent non-

conformances raised and ends with the preparation of the IQA summary

report indicating the status of the non-conformances to be reported during

Management Review Meeting.

TERMS AND

DEFINITIONS

Internal Quality Audit or IQA - a systematic, independent, and documented

process for obtaining audit evidence and evaluating it objectively to

determine the extent to which audit criteria are fulfilled.

IQA Team - a group of qualified, identified and designated personnel who shall

conduct the internal quality audit based on a documented procedure. These

personnel are also called Internal Quality Auditors.

Audit Plan is a document that contains the objective and scope of the IQA,

the date and place of audit, the functional units to audit, time and duration of

each major audit.

Non-Conformance or NC is a violation of client requirements or lapses in the

implementation of the process.

IQA Report - a document that details the results of the IQA.

Checklist - an instrument that is used to guide and/or assist the auditor in the

audit process and to provide a record of questions and observations.

Objective Evidence is an information which can be proved true based on

facts obtained through observation, measurement, test or other means.



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-IQA

Issue Status 01

Revision No. 00


Page No. 1 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

TERMS AND

DEFINITIONS Major NC is a complete breakdown of the system having a major impact to

the delivery of services to the client e.g. absence of a quality system element,

a procedure, or objective evidence of the quality systems’

implementation; non-fulfilment of statutory / regulatory requirement of CHEd.

Minor NC is a single “lapse” /”slip” of compliance to a documented quality

system or implementation thereof.

Observation means any finding that is not covered by any procedure but will

help improve the organization or a possible non-conformance in the future if it

will not be addressed.


Person/s

Details /

Reference

Lead Auditor/Team Note 1

Lead Auditor/Team Note 2

QMR / President Note 3

Lead Auditor Note 4

Internal Auditors Note 5

Internal Lead Auditor Note 6

Prepare Audit Plan

Prepare Annual Audit Program

Prepare Internal Memo / Send Notice of Audit

Review and Approval

Prepare Audit Checklist

Briefing of the IQA Auditors

A

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR


Person/s

Details /

Reference

Lead Auditor Note 7

IQA Team

Internal Auditors / Auditee

Lead Auditor

Auditee Note 8

Auditor / Lead Auditor / QMR Note 9

Auditor

Lead Auditor Note 10

Conduct of Audit

Opening meeting

Prepare Report & Discuss the findings with the Auditee

Closing Meeting

Formulate Corrective & Preventive Actions

Monitor Corrective & Preventive Actions

Close-out Non-conformance

Is Corrective/Preventive

Action effective?

Yes

Request for new Corrective/

Preventive Action

No

Update IQA Records

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 4 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 1:

1. Prepare Annual Internal Quality Audit Program (FM-USeP-IQA-01).

2. At least two regular or full audits are scheduled each year or as deemed necessary.

3. Special audits are scheduled whenever unfavorable trends are identified and reported during

operations. Unfavorable trends may include: numerous customer complaints, accidents/

emergencies, decrease in productivity. Special Internal Audits may also be conducted to

evaluate implementation of new processes critical in achieving product and process quality.

Scope of special audits may cover only areas where problems are identified.

4. The annual audit program will be prepared at least one (1) month prior the coming year to be

reviewed and approved by the QMR and the President, respectively.

NOTE 2:

1. The Audit Plan (FM-USeP-IQA-02) details the date/s, time, venue and who are the auditors of

each process and ensures that all relevant ISO clauses are covered by the auditor.

2. Considerations in scheduling the processes to be audited are:

a. Availability of Process Owners or Auditees

b. New Process

c. Number of Client Complaints

d. New Employees

SELECTION OF AUDITORS’

1. The President together with the QMR and the Management Team select auditors in the

following criteria:

At least a BS Degree holder;

Work experience in the University of at least six months;

Trained/attended or re-echoed from the attendees of the Internal Audit training

Familiar with the organization processes

At least familiar with ISO standards and management principles

For the Audit Team leader or Lead Auditor: Must have attended the Internal Quality Audit

Lead Auditor Course or have attended at least Internal Quality Audit Training/Seminar.

2. The QMR issues a written designation to the selected Auditors/Lead Auditors duly confirmed

by the President.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 5 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

LEAD AUDITOR’S AND AUDITORS’ RESPONSIBILITIES

1. Only trained personnel are allowed to conduct internal audits. Auditors’ performances are

monitored through feedbacks from auditees which also serve as inputs to the continuing

training program.

2. Auditors cannot audit their own processes/areas.

3. Methods in auditing include interview and verification of records.

NOTE 3:

1. The Audit Plan/Itinerary is submitted to the QMR and President for review and approval.

2. The Lead Auditor will revise the Audit Plan / Itinerary if it is not approved.

NOTE 4:

1. The Lead Auditor prepares internal memo and send notice of audit to each department/

office prior to the audit schedule. Likewise, the designated Internal Quality Auditors are

advised to prepare audit checklist.

NOTE 5:

1. Checklists (FM-USeP-IQA-03) may be prepared for each process with consideration on the

relevant clauses of the ISO standard, which serves as guide during audits to aid time

management, ensures depth and continuity, and to ensure all relevant aspects are covered.

2. Checklists (FM-USeP-IQA-03) may be updated during each audit.

NOTE 6:

1. A day before the audit proper, the Lead Auditor will discuss the audit plan to the IQA Team.

2. IQA Team Leader will give final details to Auditors prior to opening meeting with the auditees.

NOTE 7:

1. An opening meeting shall be held with the auditee’s management or where appropriate,

those responsible for the functions or processes to be audited.

2. The meeting should be formal and reports of the attendance should be kept. The meeting

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 6 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

should be chaired by the audit team leader.

3, The audit team shall confer periodically to exchange information, assess audit progress, and

to reassign work between the audit team members as needed.

4. Guides and observers may accompany the audit team but are not part of it. They should not

influence or interfere with the conduct of the audit.

5. Information relevant to the audit objectives, scope and criteria including information relating

to interfaces between functions, activities and processes should be collected by appropriate

sampling and should be verified. Audit evidence should be recorded. Methods to collect

information: interviews, observation of activities and review of documents.

6. A closing meeting chaired by the Audit team leader should be held to present the audit

findings and conclusions in such a manner that they are understood and acknowledged by

the auditee, and to agree, if appropriate, on the time frame for the auditee to present a

corrective and preventive action plan. Participants in the closing meeting shall include the

auditee among other parties. Minutes and attendance should be kept.

7. Any diverging opinions regarding the audit findings and/or conclusions between the audit

team and the auditee should be discussed and if possible, resolved. If not resolved, all

opinions should be recorded.

Note: While conducting the audit, auditors seek objective evidence demonstrating whether

the audited activities conform with the requirements of the organization’s Quality

Management System, ISO 9001:2008 requirements as well as statutory and regulatory

requirements.

8. The members of the audit team are responsible for the preparation of the Internal Quality

Audit Report (IQAR) (FM-USeP-IQA-04). The audit report should provide a complete, accurate,

concise and clear record of the findings of the audit.

9. The auditee fills-out the following portions of the Internal Quality Audit Report:

- Analysis of root cause(s)

- Correction

- Corrective Action

- Preventive Action

NOTE 8:

1. Formulation of correction, corrective and preventive actions.

a. Correction – are actions taken immediately to suppress the identified non-conformity

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 7 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

b. Corrective actions - are actions taken to eliminate the root cause of an existing non-

conformity, reject, or other undesirable condition to prevent recurrence.

c. Preventive actions - are actions taken to eliminate the root cause of a potential non-

conformity or other undesirable condition to prevent its occurrence.

2. The assigned auditor will approve the proposed actions and will be responsible to monitor

implementation of such.

3. The IQAR will be submitted to the Team Leader. And the Team Leader will prepare the Internal

Quality Audit Summary Report (FM-USeP-IQA-05) to be submitted to the QMR.

NOTE 9:

1. The designated Internal Quality Auditors verify the effectiveness of corrective / preventive

action taken.

2. If Corrective / Preventive Action is not effective, advise Department/Office Head and extend

period of implementation, if necessary, then indicate the details of the arrangements made in

the existing IQAR Form or issue another IQAR Form.

3. The Internal Quality Auditor will indicate the status of the corrective /preventive action in the

Summary of IQAR as Open (no action was taken). On-going (action was taken but not

completed).

4. If the Internal Quality Auditor is satisfied on the effectiveness of corrective / preventive action

taken, the non-conformances are then closed out.

NOTE 10:

1. Every internal audit shall be numbered sequentially using the IQA Register (FM-USeP-IQA-07) in

order to facilitate monitoring and referencing, such as IQA No. 01-1116 (IQA No. 01-MoYr)

which means, 01 is the first audit, 11 is the month and 16 is the last two digits of the calendar

year 2016. Thus, 01-1116 means the first Internal Quality audit for calendar year 2016

conducted in the month of November.

2. The results of the audit shall be discussed during the management review meeting.

3. The summary of the Internal Quality Audit Report will be presented to the management and

discuss realizations and findings of the internal audit conducted.

4. Internal Quality Auditors Team shall be evaluated using the Internal Auditor Evaluation Form

(FM-USeP-IQA-06).

5. The evaluation form will be submitted to the Lead Auditor or QMR for review.

6. The QMR presents the results of the evaluation during the management review.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 8 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

RECORDS GENERATED:

Annual Internal Quality Audit Program FM-USeP-IQA-01

Audit Plan FM-USeP-IQA-02

Audit Checklist FM-USeP-IQA-03

Internal Quality Audit Report FM-USeP-IQA-04

Internal Quality Audit Summary Report FM-USeP-IQA-05

Internal Auditor Evaluation FM-USeP-IQA-06

IQA Register FM-USeP-IQA-07

Corrective/Preventive Action Report FM-USeP-HNC-01

CPAR Monitoring FM-USeP-HNC-02

Minutes of Meeting

FORM/S:

Annual Internal Quality Audit Program FM-USeP-IQA-01

Audit Plan FM-USeP-IQA-02

Audit Checklist FM-USeP-IQA-03

Internal Quality Audit Report FM-USeP-IQA-04

Internal Quality Audit Summary Report FM-USeP-IQA-05

Internal Auditor Evaluation FM-USeP-IQA-06

IQA Register FM-USeP-IQA-07

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 9 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 10 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 11 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 12 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 13 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 14 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 15 of 15

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY

TITLE HANDLING OF NON-CONFORMANCE

PURPOSE/S To ensure that all nonconforming products are identified, analyze to avoid its

unintended use.

SCOPE This procedure covers activities from identification up to the analysis of non-

conformances during operations that lead to the formulation of corrective and

preventive actions.

TERMS AND

DEFINITION/S Non-conformance - an observed situation where objective evidence indicates

the none-fulfilment of a specified requirement of the Quality Management

System. It is also a fundamental breakdown of the Standard.

It is categorized into:

- Major non-conformance: a deviation from the planned arrangements which

impinges on the quality of service delivered to the customer.

- Minor non-conformance: a single lapse in a procedure or instruction which is

not critical to the operation.


Person/s

Details /

Reference


Process owners / QMR Note 2

President Note 3

QMR Note 4

Analyze Non-conforming product/output

Identify Non-conforming output

Formulate, Review and approve Actions

Implement and Monitor Actions



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-HNC

Issue Status 01

Revision No. 00


Page No. 1 of 5

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 5

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 1:

1. Identify all non-conformances during each process in operations.

2. Non-conformance can be identified in the following:

a. Non-compliance to the CHEd Memorandum Order (CMO)

b. Unapproved course design

c. inspection of purchased items

d. Unapproved Students activities and/or Organizations

e. Enrolment and Admission of Students

f. Unapproved Syllabus

g. Failure to generate records

h. Utilizing forms not prescribed to the documented system

i. Failure to monitor Quality Objectives and Targets

j. Student’s Feedback

k. and other related lapses or violation of the implementation to the established documented

system.

NOTE 2:

1. Record actions formulated in the Corrective/Preventive Action Form (FM-USeP-HNC-01).

Refer to Corrective Action procedure (PM-USeP-CAR) and Preventive Action procedure

(PM-USeP-PAR).

NOTE 3:

1. Review overall impact of the corrective/preventive actions recommended on the overall

integrity of the management system.

NOTE 4:

1. Monitor the status of implementation of the CPAR using the CPAR monitoring (FM-USeP-HNC-

02).

2. Generated reports to be discussed during Management Review which is conducted at least

twice a year.

3. For Management Review, refer to Conduct of Management Review procedure (PM-USeP-

CMR).

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 5

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

RECORDS GENERATED:



Status Reports

FORM/S:



UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 4 of 5

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 5 of 5

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY

TITLE CORRECTIVE ACTION

PURPOSE/S

To ensure all non-conformances identified during the implementation of the

management system are analyzed and actions formulated to eliminate their

root causes. This is to prevent recurrence of a non-conformance.

SCOPE This procedure covers formulation and implementation of corrective actions

for all types of non-conformances identified.

TERMS AND

DEFINITIONS Corrective Action - an action to eliminate the cause of a detected

nonconformity or other undesirable situation” – PREVENT RECURRENCE.


Person/s

Details /

Reference



QMR/President Note 3



QMR Note 6

QMR Note 7

Analyze & Formulate Action

Identify Non-Conformance

Review proposed Actions

Approve Recommended Actions

Implement Approved Actions

Monitor Implementation and finalize change

Discuss during Management Review



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-CAR

Issue Status 01

Revision No. 00


Page No. 1 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 1:

1. Identify potential non-conformances and/or improvements during the implementation of

each process, and record details in the Corrective/Preventive Action Report (CPAR) using the

FM-USeP-HNC-01 form.

2. The concerned personnel or anyone within the organization or from independent assessor

who identifies a problem in the work process, finds a non-conformance or deficiency in the

Quality Management System or work process.

3. Non-conformance or Deficiencies can be identified through the internal or external audits, by

observing the employees at work, from students’ feedback, interviews, review of documents.

The concerned personnel asks for the CPAR Form (FM-USeP-HNC-01) from the DCO and fills it

up stating the non-conformance identified.

4. The Document Controller monitors issuance of the forms and is in-charge of updating the

CPAR Monitoring (FM-USeP-HNC-02) who is supervised by the QMR.

NOTE 2:

1. The requested party or the process owner/s to whom the non-conformity is addressed takes

action based on the request.

2. If the nature of the corrective action is emergency the requested party or process owner/s fill-

out the form on the identified root-cause/s and the corrective action/s to be taken.

3. Analyze and identify root causes of the potential non-conformance and/or justifications for

improvement actions. Record result of analysis in the Corrective/Preventive Action Report (FM

-USeP-HNC-01). Formulate and recommend actions to be taken. Ensure time frames and

responsibilities for actions are clearly defined. The QMR may also help in the formulation of

preventive/improvement action.

4. The person responsible to undertake the Corrective action is to be identified. The target date

of completion is to be specified.

NOTE 3:

1. The QMR evaluates the corrective action to be taken. If it is adequate to prevent future

recurrence of the problem. If the matter is beyond the capacity of the QMR, the QMR may

refer the matter to the President.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 4:

1. If the corrective action is acceptable, the QMR or the President will approve the CPAR.

2. The Corrective Action is considered effective if after one (1) month implementation or within

the project duration and the nonconformance did not recur.

NOTE 5:

1. The implementation of the proposed actions shall be within the specified target period or

timeframes of the process owners to implement.

NOTE 6:

1. Monitor implementation of the recommended actions following defined time frames. Identify

interfaces with other processes of the management system and determine effects. If actions

taken are effective (the same problem did not recur), formalize the changes.

2. Prepare Document Change Request Form (FM-USeP-DOC-02) to revise affected

documents or to issue new documents to formalize full implementation. Refer to Control of

Documents procedure (PM-USeP-COD).

NOTE 7:

1. If the action taken is inadequate, the concerned personnel/process owner may request

another corrective action from the other entity to act on the problem.

2. If the concerned office/personnel or process owner failed to implement the corrective action

within the specified timeframe, the QMR has the option to recommend directly to the

President for proper action, which will be discussed during the Management Review meeting

for deliberation.

RECORDS GENERATED:



UNCONTROLLED C

OPY



MASTER COPY

TITLE PREVENTIVE ACTION

PURPOSE/S

To ensure all potential non-conformance identified during the implementation

of the management system are analyzed and actions formulated to eliminate

their root causes. This is to prevent occurrence of a potential non-

conformance.

SCOPE This procedure covers formulation and implementation of preventive actions

for all types of potential non-conformances and/or improvement actions

identified.

TERMS AND

DEFINITION/S Preventive Action - is an action to eliminate the cause of a potential

nonconformity or other undesirable potential situation” – PREVENT

OCCURRENCE.



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-PAR

Issue Status 01

Revision No. 00


Page No. 1 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR


Person/s

Details /

Reference






QMR Note 6

QMR Note 7

Identify Potential Non-Conformance or Improvement

Review proposed Actions

Approve Recommended Actions

Analyze & Formulate Action

Implement Approved Actions

Monitor Implementation and formalize change

Close-out Preventive Action

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 1:

1. The concerned personnel or anyone within the organization or from independent assessor

who identifies an area where a possible or potential problem may be present.

2. He/she may discuss to the QMR and ask assistance on what and how to gather data or

information to support his/her claim that a possible or potential problem may be present.

NOTE 2:

1. After the analysis and gathering of data, the concerned personnel asks for CPAR form (FM-

USeP-HNC-01) and fills up the form and attach necessary data gathered and submit it to the

QMR who in turn records appropriate entries.

NOTE 3:

1. The QMR reviews the submitted report and data gathered in coordination with other

personnel identified by the QMR that may be able to help to formulate action plans.

2. The concerned office must agree on what action plan is to be taken.

NOTE 4:

1. If the Preventive action is acceptable, the QMR or the President will approve the CPAR.

2. The Preventive Action is considered effective if after one (1) month implementation or within

project duration and the nonconformance did not recur.

NOTE 5:

1. The implementation of the proposed actions shall be within the specified target period or

timeframes of the process owners to implement.

2. The concerned personnel identified to implement the action plan undertake the necessary

measures as agreed.

3. Any problem in the implementation may be discussed in another meeting, be it formal or

informal, to clarify the implementation plan.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 3

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 6:

1. Monitor implementation of the recommended actions following defined time frames. Identify

interfaces with other processes of the management system and determine effects. If actions

taken are effective (the same problem did not recur), formalize the changes.

2. Prepare Document Change Request Form (FM-USeP-DOC-02) to revise affected

documents or to issue new documents to formalize full implementation. Refer to Control of

Documents procedure (PM-USeP-COD).

NOTE 7:

1. Closing-out of the Preventive Action.

The QMR initiates the meeting to follow-up the progress of the action taken on the

agreed date to make a follow-up discussion.

The same persons who formulate and finalize the action to be taken are the ones to

attend this meeting.

The group must agree whether the action taken is effective or not.

If not effective, the concerned personnel will file another CPAR so that another action

plan will be formulated. In this case, preventive action will not be closed but notations

will be written that another CPAR is filed for another action plan.

If a problem occurs before the closing out of the preventive action taken, a CPAR

request will be filed following the Corrective Action procedure (PM-USeP-CAR).

RECORDS GENERATED:



UNCONTROLLED C

OPY



MASTER COPY

TITLE OBJECTIVES AND TARGET SETTING

PURPOSE/S

To ensure that directions and targets are set based on the vision, mission, goals

and quality policy of the Organization.

To ensure programs are formulated that are aligned to these set of directions.

SCOPE This procedure covers steps from planning, goal setting and program

formulation to review and approval of formulated action plans.

TERMS AND

DEFINITION/S Objectives and Targets of the University are based on the established Agency

Performance Commitment and Review (APCR).



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-OTS

Issue Status 01

Revision No. 00


Page No. 1 of 4

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR


Person/s

Details /

Reference

President/Management

Team Note 1


Team Note 2


Team Note 3


Team Note 4

QMR Note 5

Review Vision, Mission, Goals, Quality Policy

Formulate Strategic Action Plans

Review and Approve Summary of Objectives

Formulate Objectives and Targets

Implement Approved Plans

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 4

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 1:

1. The review includes:

a. Operations results of previous year.

b. Achievement of the Quality Policy and objectives of previous year.

2. Minutes of meeting shall be prepared for the results of review.

NOTE 2:

1. Formulate targets and objectives based on the Agency Performance Commitment and

Review (APCR). Ensure that the objectives (goals) and targets are consistent with the

customer needs, wants and expectations.

2. Ensure that the targets are aligned to the Quality Policy.

3. The quality policy sets out the USeP vision, mission and goals. The stated policy in the QMS

may be extracted, published and placed in accessible areas within Malita campus. This shall

provide the USeP’s Students, Suppliers, Certifying or Accrediting bodies information on its

intention of rendering quality service to its clientele.

4. The Quality Policy shall be posted in a conspicuous area for wide dissemination and

information to the USeP employees, students, and visitors/guests.

NOTE 3:

1. Prepare Monitoring of Objectives and Targets (FM-USeP-OTS-01) addressing issues on human

resource administration, student-related, quality objectives, customer satisfaction plans, and

current and future customer expectations.

2. Define responsibilities and time frames.

3. Ensure that the responsibilities are distributed to all relevant functions to ensure that activities

are implemented on time.

4. Ensure that all personnel included in the plans understand and agree on the functions

assigned to them.

NOTE 4:

1. Consider completeness, significance and attainability of the plan.

2. Consider the practicability and feasibility of the plans with regard to the company’s available

resources.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 4

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

3. Ensure that the plans address the significant concerns and requirements of all stakeholders.

4. Ensure that each process has corresponding objectives and targets set.

NOTE 5:

1. Monitor implementation. Ensure that a monthly actual data is compiled every after end of

the month. Use the Monitoring of Quality Objectives and Targets (FM-USeP-OTS-01) to record

the monthly data.

2. There shall be evaluation through Internal Quality Audits to verify the effectiveness in the

implementation of the Quality Management System and conformance to the established

standards and to the statutory and regulatory requirements.

3. Any discussions pertaining to the status of targets and plans would have to be recorded in

the Minutes of Meetings.

4. CPAR for unmet targets is prepared quarterly. Refer to Corrective Action Procedure (PM-USeP

-CAR).

RECORDS GENERATED:

Monitoring of Quality Objectives and Targets FM-USeP-OTS-01

CPAR FM-USeP-HNC-01


Minutes of Meetings

FORM/S:

Monitoring of Quality Objectives and Targets FM-USeP-OTS-01

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 4 of 4

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY

TITLE CONDUCT OF MANAGEMENT REVIEW

PURPOSE/S To ensure the management system’s continuing suitability, adequacy and

effectiveness through periodic reviews.

SCOPE This procedure covers activities in conducting a management review. This is

done at least twice a year.

TERMS AND

DEFINITIONS

Management Review - the process of reviewing the QMS by top management

at planned intervals in accordance with the requirements of ISO 9001:2008

Standard.

Review Input - the seven items specified in section 5.6.2 of the Standard.

Review Output - the decisions and actions related to the improvement of the

QMS.


Person/s

Details /

Reference

QMR Note 1

President/QMR Note 2

QMR / Appointed Secretary Note 3

QMR Note 4

QMR Note 5

Conduct Management Review Meeting

Schedule Management Review Meeting

Prepare Minutes of the Meeting

Monitor Implementation of Resolutions

Discuss Results in Subsequent Review



Telefax: (082) 221-7737; 227-5524


Document No. PM-USeP-CMR

Issue Status 01

Revision No. 00


Page No. 1 of 4

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 2 of 4

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 1:

1. The Management Review Team shall convene and conduct a Management Review meeting

to review the Quality Management System’s adequacy and effectiveness and to assess

opportunities for improvement and the need for changes in the QMS including the quality

policy and quality objectives.

2. The QMR prepares the schedule of the management review meeting and seeks approval

from the President.

3. The QMR prepares notice of meeting informing concerned personnel prior the schedule of

the management review meeting.

NOTE 2:

1. The President or the QMR in the absence of the President shall preside the meeting and

ensures the attendance of appropriate key Office Personnel.

2. A secretary of the meeting is appointed to transcribe discussions. Attendance sheet is routed

and signed by the persons present in the meeting.

3. The QMR will read the minutes of the previous meeting. It will serve as the review of what

were discussed before.

4. The inputs to be discussed in the meeting shall include the seven (7) review inputs, which are

as follows:

1. Results of the internal and external audits;

2. Customer feedback;

3. Process performance and product conformity;

4. Status of preventive and corrective action;

5. Follow-up actions from previous MRC meetings;

6. Changes that could affect the QMS;

7. Recommendations for improvement

5. The review outputs from the MR meetings shall include any decisions and actions related to:

1. Improvement of the effectiveness of QMS and processes;

2. Improvement of services related to customer requirements;

3. Identification of resources needed.

6. Ensure that all required agenda is discussed at least twice a year or as the need arises.

7. Refer to Corrective Action Procedure (PM-USeP-CAR) and Preventive Action Procedure (PM-

USeP-PAR) for resolution of issues.

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 3 of 4

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

NOTE 3:

1. The Secretary will prepare the minutes of the meeting to include the discussions and action

plan / responsibilities designated.

2. Prior to approval, the QMR will review the Management review minutes of meeting (FM-

USeP-CMR-01).

3. The Secretary will distribute copies of the minutes of meeting to the concerned participant.

NOTE 4:

1. Monitor and follow-up actions taken. And it shall be made by the QMR or his designated

representative based on the scheduled target for completion to check the compliance of

the action.

NOTE 5:

1. Updates shall be noted and to be included in the report of the QMR and to be submitted to

the President for discussion during the next management review meeting.

RECORDS GENERATED:

Management Review Minutes FM-USeP-CMR-01

Agenda for Management Review Meeting

Attendance Sheet

Notice of Meeting

FORM/S:

Management Review Minutes FM-USeP-CMR-01

UNCONTROLLED C

OPY



MASTER COPY



Telefax: (082) 221-7737; 227-5524



Issue Status 01

Revision No. 00


Page No. 4 of 4

PROCEDURES MANUAL

MASTER COPY


_________________________________


President

_________________________________

ARISTEO C. SALAPA

QMR

UNCONTROLLED C

OPY

