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Surveillance and Reassessment

PUBLIC PROCEDURE CAP-PR-316 Issued: 2017-4-7, Revision: 2

References 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-315: Application and Initial Assessment Process
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
ASTM E2659-09, Standard Practice for Certificate Programs
1.1The objective of this document is to establish the procedures for surveillance and reassessment of the certificate issuers under ASTM E2659-09.
3Continuing Accreditation (Surveillance)
3.1Continuing accreditation assessment activities (surveillance) shall commence 12 months after the date of initial accreditation, as indicated on the ANSI certificate of accreditation. The purpose of these activities shall be to:
a)determine that the certificate issuer continues to operate in conformity with ANSI requirements and the requirements of ASTM E2659-09;
b)determine that the certificate issuer continues to operate as described in the documentation governing the program;
c)determine if any major changes reported have affected the conformity of the program to ASTM E2659-09 or ANSI requirements.
3.2Continuing accreditation activities shall include but not be limited to:
a)headquarters assessment of selected requirements (ASTM E2659-09) and/or satellite sites, if applicable;
b)other visits and assessments needed to confirm that the program is in conformance as set forth in the program documents approved by ANSI and in accordance with ANSI requirements;
c)assessments of the certificate issuer functions to ensure that the systems and personnel operations continue to be in conformity with the program document(s) approved by ANSI;
d)submission of an annual surveillance self-report report as determined by the ANSI accreditation program.
3.3The certificate issuer shall submit an annual surveillance self-assessment report on a date to be determined by ANSI staff but prior to the initial anniversary accreditation date.
3.3.1Three months prior to the annual surveillance, ANSI staff shall send the required annual surveillance self-assessment report forms and a reminder to the certificate issuer regarding the due date for the submission of their report. The certificate issuer must return a completed surveillance report. The certificate issuer can request an extension that is subject to approval by the ANSI Program Director.
3.3.2The surveillance self-report shall be submitted to ANSI in three copies. ANSI staff shall review the report for completeness and if necessary, request the certificate issuer for clarification.
3.3.3After staff review, the copies of the report are forwarded to the two selected assessors for their document review.
3.3.4Certificate issuer shall have the opportunity to approve or reject the assessment team based on the conflict of interest, similar to the initial assessment process described in CAP-PR-315.
3.3.5Failure to submit a complete annual surveillance self-assessment report may result in ANSI administrative action(s) and/or CAPAC accreditation action(s), including withdrawal of accreditation.
3.4If additional materials are needed to determine if a requirement is met, the same timelines and consequences regarding the submission of materials as listed in CAP-PR-315 shall apply.
3.5During the first and third year after the year in which the certificate issuer was accredited or reaccredited, ANSI surveillance onsite assessment shall be conducted in addition to document review. During other years, surveillance shall be limited to document review unless ANSI determines that an unscheduled onsite assessment is necessary in order to ascertain compliance of the accredited certificate issuer with the ANSI and ASTM E2659-09 requirements. See Figure 1 below.
3.6The assessors shall submit to ANSI a surveillance report. This report shall be reviewed for accuracy, including review by the certificate issuer similar to the initial assessment process. The report shall include statements on compliance of the certificate issuer with each clause of the standard as well as all identified nonconformity(ies). All nonconformities must be closed within 90 days. CAPAC may grant additional time to close a nonconformity based on its severity and corrective action implementation target date.
3.7Surveillance report, including the implemented corrective actions or the proposed plan for their implementation by the accredited certificate issuer is reviewed by the CAPAC Evaluation Task Group (ETG). ETG in turn makes recommendation to full CAPAC which makes decision in accordance with CAP-PR-319 and CAP-PL-302.
3.8ANSI staff shall notify the accredited certificate issuer of the CAPAC decision within 10 business days.
4.1Accredited certificate issuer shall undergo full reassessment every five years.
4.2Reaccreditation process follows the application and initial assessment process almost entirely with the following exceptions:
a)no preliminary application stage is required;
b)no application fee is due. Instead, the CB must submit the annual fee form;
c)assessment team shall consider the data from previous years in making their assessment decisions;
d)if an accredited certificate issuer is issued non-conformities during the reassessment which are not properly closed by the five year anniversary date of accreditation, CAPAC may vote to extend the validity date of accreditation for the certificate issuer for a limited amount of time pending the satisfactory closure of the non-conformities. This decision is made by CAPAC.