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Application and Initial Assessment Process

PUBLIC PROCEDURE CAP-PR-315 Issued: 2016-10-10, Revision: 2

References ANSI-PR-004: Appeals
CAP-FR-304: Application for ANSI Accreditation under ASTM E2659-09
CAP-PL-302: Operating Policy of the ANSI Personnel Certificate Accreditation Program Accreditation Committee (CAPAC)
CAP-PR-319: Conditions for Granting, Maintaining, Extending, Reducing, Suspending or Placing on Probation and Withdrawing Accreditation
CAP-PR-322: Fees - Accreditation of Personnel Certificate Programs
CAP-PR-345: Assessor Manual for Certificate Issuer Accreditation
ASTM E2659-09, Standard Practice for Certificate Programs
ISO 19011:2002, Guidelines for quality and/or environmental management systems auditing
ISO/IEC 17011:2004, Conformity assessment - General requirements for accreditation bodies accrediting conformity assessment bodies
Contents
1Objective
1.1The objective of this procedure is to document the application and initial assessment process for certificate issuers applying for ANSI accreditation.
2Definitions
None.
3Preliminary Application Process
3.1Certificate issuer interested in pursuing ANSI accreditation must first submit a preliminary application to demonstrate that it satisfies the following four basic requirements:
a)conforms with the definition of certificate issuer per ASTM E2659-09;
b)is a legal entity or part of a legal entity;
c)demonstrates documented authority to administer the certificate program and ensure compliance with the provisions of this practice;
d)provides evidence of a published scope(s) of the certificate program.
3.1.1Preliminary application shall also contain the list of certificate programs (scope of accreditation) that the certificate issues wishes to submit for accreditation.
3.2ANSI staff shall review the preliminary application within 20 business days of its receipt and if appropriate, issue a written statement indicating the eligibility of the certificate issuer to proceed with the full application. Staff shall also notify the Chairperson of the ANSI Certificate Accreditation Program Accreditation Committee (CAPAC). In addition, a program agreement shall be sent to the applicant to sign agreeing to follow all ANSI accreditation policies and procedures and pay the appropriate fees when requested.
3.2.1If ANSI staff determines that the applicant does not meet the basic eligibility requirements for entering the application process, the applicant shall be advised in writing of the specific requirement(s) not sufficiently documented in their materials submitted to enter the accreditation process. In this case, the applicant may submit further documentation, as requested, within 90 calendar days.
3.2.2If the certification issuer disagrees with the determination in 3.2.1, it may follow the ANSI appeals process in accordance with ANSI’s appeals procedures.
4Application for Accreditation
4.1Certificate issuers must submit the completed application (CAP-FR-304) in three copies (paper/electronically or both). ANSI shall not review applications until the application fee per 3.2 is paid in full and signed accreditation agreement is on file with ANSI.
4.1.1From the time ANSI issued a statement of eligibility per clause 3.2, applicant shall have 12 months (except for extenuating circumstances) within which they must submit all documents that are required as part of the full application package. If the application package is not complete within the timeframes indicated, applicant shall be notified that they must resubmit the application and pay a new application fee in order to restart the accreditation process.
4.2Upon receipt of the application, ANSI Staff shall:
a)send confirmation to the applicant within 5 business days;
b)notify the CAPAC Chair and request permission to seek volunteers to serve on the CAPAC Evaluation Task Group (ETG) that will be charged with the detailed review of the application.
4.3The assessment team shall be selected by ANSI staff from a list of qualified assessors without any known conflict of interest. A Lead Assessor shall be designated by ANSI staff. All assessors shall have an understanding sufficient to make a fair assessment of the competence of the certificate issuer to operate the specific certificate programs submitted for accreditation.
4.3.1One or more assessors may be rejected by the applicant due to a conflict of interest. The applicant has 10 calendar days to object to a named assessor and must do so in writing. Assessor objections will be reviewed on a case by case basis by ANSI staff in consultation with the CAPAC Chair if needed. A conflict of interest may be determined if:
a)the assessor has ever worked for the applicant;
b)the assessor is currently or has previously worked for a major competitor of the applicant;
c)the assessor has a significant personal or business relationship with the applicant or its employee(s) or a close family member.
4.3.2If no objection is received per 4.3.1, the assessment team shall be considered approved.
4.4ANSI staff shall review the application for completeness, ensuring that all the required sections have been filled out properly. Additional information and/or clarification may be requested from the applicant. This review shall be completed within 10 business days from the date of receipt, and the applicant certificate issuer shall be notified accordingly.
4.4.1If application is determined to be incomplete, ANSI shall:
a)advise the applicant that the additional materials must be submitted to ANSI within 90 calendar days for ANSI to continue to review the documentation;
b)advise the applicant that if the additional materials are not submitted to ANSI within 90 calendar days, the application shall be considered to be withdrawn and the applicant would have to start the application process from the beginning. The applicant shall be notified in writing if this action is taken.
4.4.2If application is deemed as complete, ANSI staff shall:
a)update the status of the certificate issuer to “Applicant” in ANSICA and ensure that the certificate issuer appears in the ANSI web directory of applicants.
b)request publication of the announcement of application in Standards Action. The announcement shall contain instructions for submitting comments to ANSI.
4.4.2.1A 30-day comment period is established for public comment on the application for accreditation. In order to be accepted, public comments must specifically relate to the certificate issuer or its certificate program(s) not conforming to one of the requirements of ASTM E2659-09 or other ANSI accreditation requirements.
4.4.2.2ANSI shall acknowledge receipt of all comments and provide the applicant and the assessors with a copy. Comments submitted shall not be anonymous. Where appropriate, the applicant shall be requested to provide ANSI with a response to the comment(s). Copies of all correspondence shall be provided to the assessors.
5Initial Assessment
5.1The assessors shall be provided with copies of the application by ANSI staff and will begin their document review. Lead Assessor conducts the review with input from the other assessor(s). The assessors may require the applicant to provide additional information for the purposes of clarification and further documentation indicating how the requirements are being met.
5.1.1If additional documentation is required by assessors, the same timelines and consequences regarding the submission of materials as listed in 4.4.1 shall apply.
5.1.2The purpose of the document review is to:
a)determine if written policies and procedures, education and training documents and other related data comply with the ASTM E2659-09 and the ANSI accreditation requirements;
b)provide a basis for the development of an onsite assessment plan;
5.1.3ANSI may decide not to proceed with an onsite assessment based on the nonconformities found during document and record review. In such cases, the nonconformities shall be reported in writing to the applicant.
5.2The assessors shall work with the applicant to schedule and conduct an onsite assessment in accordance with CAP-PR-345: Assessor Manual for Certificate Issuer Accreditation.
5.2.1The assessors, in conjunction with the applicant and ANSI staff, shall develop an assessment plan. The plan shall include:
a)dates and expected length of onsite assessment;
b)tentative schedule for the assessment;
c)individual or group interviews;
d)observation of any training or educational activities;
e)description of activities to be accomplished during the assessment;
f)requested materials to be available on site.
5.2.2Any disagreement between the assessors and the applicant regarding the assessment plan shall be reviewed by ANSI staff and, if necessary, CAPAC representative(s).
5.2.3If the certificate issuer operates programs that spread across multiple sites with no one site housing all the activities that need to be assessed, assessment shall cover as many additional sites as necessary to collect objective evidence to verify that the documented policies and procedures are implemented. Since multi-site assessment will incur additional costs, access to relevant documentation from certain sites may be provided at a central location such as headquarters. However, all key locations as defined in ISO/IEC 17011 shall be assessed.
5.2.4While conducting the onsite assessment, ANSI assessors shall apply the general principles of ISO 19011:2002, Guidelines for quality and/or environmental management systems auditing.
5.2.5The purpose of the onsite assessment is to:
a)determine whether the certificate issuer and its programs operate as described in the application submitted to ANSI and other documents governing the operation of the programs;
b)further validate that the programs are operating in conformity with ASTM E2659-09 and ANSI accreditation requirements;
c)conduct interviews and ensure that additional information that could not be reviewed prior to the onsite assessment or must be reviewed under secure conditions, such as databases, statistics, files and records is reviewed.
5.2.6An opening meeting shall be conducted to review the purpose of the onsite and the agenda. During the opening meeting the applicant may ask questions about the process, make changes to the agenda due to last minute circumstances and address any logistical issues that need to be discussed.
5.2.7Prior to leaving the site, assessors shall report to the applicant on the findings including strengths, opportunities for improvement and non-conformities during the closing meeting. This provides the applicant an opportunity to discuss any of the findings. If nonconformities have been identified, applicant shall be given access to them via ANSICA.
5.3After the onsite assessment has been conducted, an assessment report covering all of the assessment activities is prepared by the Lead Assessor with input from the other assessor(s) and submitted to ANSI staff for review within 15 working days (three weeks). After ANSI staff reviews the report, it is sent to the applicant for their review of any misstatement of facts. All requests for changes shall be reviewed by the assessors.
5.3.1The report will contain the following information:
a)personnel interviewed;
b)any activities observed;
c)additional document(s)/data reviewed onsite;
d)determination for each requirement: met / commendation / opportunity for improvement / nonconformity;
e)evidence for identified nonconformities.
5.4Assessment report and the findings are forwarded to ETG for their review. An in-person meeting or a conference call may be set up by ANSI staff between the ETG members and the assessment team to discuss the results of the assessment. The ETG may direct the assessors to make modifications to the report and findings if necessary. The ETG and the assessors shall work to reach a consensus regarding the findings. If a consensus cannot be reached, it is referred to the full CAPAC.
5.5All nonconformities must be closed before accreditation can be awarded by CAPAC. If there are open nonconformities, the ETG may recommend to the CAPAC a timeframe to be allotted to the applicant certificate issuer in order to provide satisfactory corrective actions. In some cases, the non-conformities may be serious enough for ETG to recommend that the accreditation be denied.
5.6Once all the non-conformities are closed, CAPAC shall consider accreditation action based on the ETG recommendation in accordance with CAP-PR-319 and CAP-PL-302.
5.7If accreditation is awarded by CAPAC, the ANSI staff shall prepare certificate of accreditation signed by the ANSI Vice President, Accreditation Services and promptly send it to the certificate issuer. The effective date of accreditation shall be the day of the accreditation decision by the CAPAC. The certificate shall indicate:
a)identity and logo of the accreditation body;
b)name and the unique accreditation ID of the accredited certificate issuer;
c)a list of accredited certificate programs (scope) as well as all the accredited key locations;
d)the effective and expiry date of the accreditation period;
e)any appropriate normative documents or standards.
5.8ANSI shall include the newly accredited certificate issuer in its online directory. This posting shall include the following: demographic information and contact person(s), website, beginning and end dates of accreditation and a list of accredited certificate programs.
5.9ANSI shall announce accreditation in Standards Action and duly review all relevant public comments. These comments may potentially become a reason for extraordinary assessment of the certificate issuer.

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