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Certificate Accreditation Program Guidance Document

PUBLIC GUIDANCE CAP-GI-301 Issued: 2009-7-7, Revision: 0

References
Contents
1Objective
1.1Objective of this document is to provide guidance on ASTM E2659-09 for potential applicants for ANSI's accreditation program for personnel certificate programs. This document supplements ASTM E2659-09 which should be purchased separately from the ANSI web store.
2Definitions
None.
3Guidance Template
Standard ElementSummary of RequirementClarification of requirement as neededTypical Assessment EvidenceAnnual Report

Note: Will be addressed at conclusion of pilot
Document ReviewOn-site Review
5.1 Organizational Structure and Administration
5.1.1
5.1.1 Certificate issuer is (or is within) a legal business entity or governmental agency
The certificate issuer may be a department or unit within a legal business entity.Articles of incorporation, bylaws if appropriate or legislation authorizing the government entity
5.1.25.1.2.1 Certificate program purpose, scope and learning outcomes are aligned with the organizational missionOrganizational mission, certificate purpose, scope and learning outcomes
5.1.35.1.3 An authority has been clearly designated.Authority may be an individual or group, dependent upon the organization scope, size, structure, etc. The key is that there is an entity with overall responsibility, even if several individuals or groups are involved in the program.Policies and procedures, organizational chart, job description(s) and/or certificate program plan
5.2 Management
5.2.15.2.1 Policies and procedures are fair, equitable and comply with regulatory and statutory requirements and legal obligationsPolicies and proceduresPersonnel interviews
Observation
Record review
5.2.1.1 Policies and procedures required by the standard existPolicies and procedures for 5.2.1.1 (1) through (11) must be documented.Policies and procedures
5.2.1.2 Personnel are assigned to implement the policies and procedures systematically and effectively and a framework for implementing policies and procedures is clearly defined and understoodIt is not enough to have a policy and procedure manual; personnel need to be assigned to implement the policies and procedures and a system set up to assure they are implemented. Organizational chart, job descriptions, personnel communicationsPersonnel interviews
5.2.25.2.2.1 Personnel qualifications are definedJob descriptions
5.2.2.2 There are sufficient and qualified staff Organizational chart, job descriptions and certificate program plan, resumes, training recordsPersonnel interviews
5.2.2.3 Personnel qualifications are evaluated on ongoing basis and training and development plans are implemented, when necessary Training and development plans, personal professional development plansPersonnel interviews
Record sampling review of relevant personnel files, professional development records
5.2.35.2.3.1 Program finances are clearly identified and show financial stabilityA review of some type must be conducted to ensure check and balances are in place to verify financial information. For established programs, financial reports for the past three years must be provided. Programs newer than three years must provide data to demonstrate financial stability such as business plans which show projected sources of funding.Financial reports or business plansFinancial files that could not be sent out for document review
5.2.3.2 Written procedures exist for financial controlsPolicies and procedures
5.2.45.2.4.1 Certificate issuer makes the required information available to primary stakeholders in advance of the program See definition of primary stakeholder in Section 3: Terminology.

Required information for items 5.2.4.1 (1) to (9) must be provided.
Policies, website, brochures or other promotional materials provided to primary stakeholders.Interview participants
5.2.4.2 Certificate issuer represents the program accurately and responsiblyPolicies, website, brochures or other promotional materials provided to primary stakeholders.

Document review to verify claims made.
Interviews with personnel and certificate holders and participants.
5.2.4.2 (1) Certificate issuer does not state or imply certificate holders are certified, licensed, accredited or registeredPolicies, website, brochures or other promotional materials provided to primary stakeholders.Interviews with personnel and certificate holders and participants.
5.2.55.2.5.1 If contractors or collaborators are used, the certificate issuer maintains responsibility for quality and conformance with the standard's requirementsExamples of contractors or collaborators would include co-sponsors, vendors, consultants, subcontractors, business partners. Contracts/agreements
5.2.5.1 (1) Contracts clearly specify responsibilities assigned and include confidentiality and conflicts of interest provisionsServices substantially related to the certificate program process must have contracts / agreements meeting these requirements.Contracts/agreements
5.2.5.1 (2) Certificate issuer ensures contractors or collaborators are qualified to carry out responsibilities assigned and monitors performanceContractor/collaborator proposal evaluations, internal audits
Evidence of corrective actions taken based on performance
Personnel interviews to include any contractors or collaborators
5.2.5.2 Decision to issue certificate is not outsourcedAll other program elements except the actual decision to issue the certificate may be outsourced.Contracts/agreements
5.2.5.3 If external financial support received, the certificate holder maintains responsibility for quality and conformance with the standard's requirements and no undue influence existsContracts/agreements, formal meeting summaries/minutes
5.2.5.3 (1) Commercial support and disclosure policies and procedures existEvidence needs to be provided that commercial support and disclosure policies and procedures are understood and implemented by relevant personnelPolicy and procedures
Personnel interviews
5.3 Internal Audits
5.3.1 5.3.1 Internal audits are planned and performed regularly (at least annually)See definition for internal audit in Section 3: Terminology.

Audits may be conducted by in-house personnel or consultants/vendors, but not by personnel who are directly responsible for the program
Audit plans, audit reports
(most recent)

Contracts if applicable
Interviews with individuals who conducted audits
5.3.25.3.2 Audit results are communicated to managementAudit-related communications
5.3.35.3.2 Audit results are communicated to managementAudit related communications and follow-up reports Personnel interviews
5.4 Record and Document Control Systems
5.4.15.4.1 Individual(s) are assigned responsibilityThe individual assigned responsibility may have other responsibilities.Policies and procedures, job descriptionsPersonnel interviews
5.4.25.4.2 Records control policies and procedures are understood and implemented by relevant personnelFor 5.4.2.4 and 5.4.2.5, refer to term of validity definition in Section 3: Terminology and section 6.2.4

The standard does not specify the number of years for which the records must be kept; however, certificate issuers must develop their own policies and provide rationale.
Personnel interview
Sample records
5.4.2.1 Policies and procedures address which records are kept, by whom, for how Document review of policies and proceduresSample records
5.4.2.2 Records of credits are maintained consistent with applicable agency Policies and proceduresSample records
5.4.2.3 Records of certificates are maintained for period beyond certificate term of validityPolicies and procedures Sample records
5.4.2.4 Learners and certificate holders are able to receive verification and documentation of progress or completion of program, credits earned, certificate issue date and term of validityPolicies and procedures
Websites, brochures or other public communication.
Obtain information based on assessor requests
5.4.2.5 Stakeholders are able to confirm certificate term of validityPolicies and procedures
Websites, brochures or other public communication
Personnel interviews
Pull a sample of certificates
5.4.35.4.3 Privacy, confidentiality and secure handling policies and procedures are understood and implemented by relevant personnelPersonnel interview
Sample records
5.4.3.1 Privacy of participants is reasonably respected and maintainedPolicies and proceduresPersonnel interviews

Record sampling review of related complaints
5.4.3.2 Confidential information is held in confidence and in secure mannerPolicies and proceduresPersonnel interviews

Record sampling review to ensure compliance with policies and procedures
5.4.3.3 Primary stakeholders are informed about what types of information are treated as confidential and the conditions for their disclosure.Policies and procedures, websites or other communication vehicles
5.4.45.4.4 Document control policies and procedures are understood and implemented by relevant personnelTransient documents --documents that have a single version life – (i.e. they are released and are stored or destroyed, like memos, emails, agendas) need not be controlled.

Proper control of documents includes who is responsible.
Personnel interviews

Record sampling
Determine if documents are present and located where designated
5.4.4.1 Procedures address proper document creation, approval, revision, and re-approval, distribution, and prevention of obsolete document usePolicies and proceduresRecord sampling review of current controlled documents
5.5 Complaints and Appeals
5.55.5 Complaints and appeals policies and procedures are understood and implemented by relevant personnelComplaints and appeals are distinct concepts; see definitions in Section 3: Terminology.Personnel interviews

Record sampling review of actual appeals and complaints
5.5.15.5.1 Complaints and appeals policies and procedures are published and accessible to stakeholdersAccessible means available either through published documents or websiteWebsite, stakeholder communications
5.5.25.5.2 Appeals and complaints are resolved in unbiased and timely mannerTimeframes must be included in policies and proceduresRoster of persons involved in appeals and associated conflict of interest statements, recent appeals and related communicationsRecord sampling of appeal records / minutes
6.1 Certificate Program Plan
6.1.16.1.1 Certificate program plan is documentedRefer to definition of certificate program plan in Section 3: Terminology.Certificate program plan
6.1.26.1.2 Oversight committee exists to develop, monitors and approves the certificate program planPolicies and procedures, organization chart, committee rosters/bios, meeting minutes/notes
6.1.2.1 Members represent balance of interests and expertise from primary stakeholdersRefer to primary stakeholder definition in Section 3: Terminology.Policies and procedures, committee rosters/bios
6.2 Analysis, Design, Development, Implementation and Evaluation
6.2.16.2.1 Certificate program target audience and purpose are identifiedDescription of target audience must be in enough detail to identify if program purpose and scope are aligned to the audience.Certificate program plan, formal meeting summaries/minutes, brochures, website
6.2.2 6.2.2 Program scope and learning outcomes are based on primary stakeholder needsCertificate program plan, formal meeting summaries/minutes, research
6.2.2.1 Needs identification process and link to program scope and learning outcomes are documented Documented process must be consistent with training/learning industry-accepted practices.
Certificate program plan (including needs assessment reference), formal meeting summaries/minutes, needs assessment tool/reports
6.2.36.2.3 Certificate requisites are defined and validated by oversight committeeIn this context, validated means that the oversight committee has reviewed and approved the requisites based on professional judgment.Certificate program plan, formal meeting summaries/minutes
6.2.3.1 Requisites aligned with program purpose, scope and learning outcomesRationale must be provided supporting requisite alignment.Certificate program plan, formal meeting summaries/minutes
6.2.3.2 Requisites include 1) minimum participation requirements and 2) minimum achievement requirements for learner assessment(s) Examples of minimum achievement requirements for learner assessment include a passing score for a test, have met certain experiential requirements etc.Certificate program plan, brochures, website, formal meeting summaries / minutes
6.2.3.3 Requisites do NOT include provisions for testing out (or waiving) full or majority of learning event(s) and do NOT include renewal requirementsCertificate program plan, brochures, website, formal meeting summaries / minutes
6.2.46.2.4 Term of validity is identified based on program purpose, scope, learning outcomes and anticipated rate of content obsolescenceRefer to term of validity definition in Section 3: Terminology.
Rationale for the term of validity must be provided, and if available, the supporting data.
Certificate program plan, brochures, website, formal meeting summaries / minutes
6.2.56.2.5.1 Course/curriculum is designed, developed, delivered by qualified personnel and following training and education industry accepted practicesPersonnel can be staff, consultants or volunteers.

Qualified personnel means that their training, education and experiences are aligned with their certificate program responsibilities.

Certificate issuer must include a reference or references to support their practices.
Personnel resumes, training log, certificate program plan, brochures, website, formal meeting summaries/minutes, course outlines, course modules Personnel interviews Observe a learning event
6.2.5.2 Course/curriculum is aligned with program purpose, scope and learning outcomesCertificate program plan, brochures, website, formal meeting summaries / minutes, course Personnel interviews Observe a learning event
6.2.5.3 Course/curriculum delivery is appropriate to program purpose, scope and learning outcomesExamples of delivery include presentation, reading, facilitation, observation, experiential learning, demonstration, etc.Document review of certificate program plan, brochures, website, formal meeting summaries / minutes, course outlines, course modulesPersonnel interviews Observe a learning event
6.2.66.2.6.1 Learner assessment is designed, developed, delivered by qualified personnel and following training and education industry accepted practicesPersonnel can be staff, consultants or volunteers.

Qualified personnel means that their training, education and experiences are aligned with their certificate program responsibilities.

Certificate issuer must include a reference or references to support their practices
Resumes, certificate program plan, brochures, website, formal meeting summaries/minutes, assessment instruments

Personnel interviews
6.2.6.2 Learner assessment is aligned with and assesses learner achievement of learning outcomesAlignment of assessment to the learning outcomes must be documented.Certificate program plan, policy manual, formal meeting summaries / minutes, assessment instruments
6.2.6.3 Learner assessment methods and delivery are appropriate for and consistent with program purpose, scope and learning outcomesCertificate program plan, policy manual, formal meeting summaries / minutes, assessment instruments
6.2.6.4 Learner assessment provides opportunity for learners to provide feedback on the method or instrument contentCertificate issuer must document the feedback process.Certificate program plan, policy or procedures, assessment instrument, feedback forms
6.2.6.5 Procedures are in place to verify learner identity and ensure instrument security Brochures, program plan, policy manual, procedures

Personnel interviews

Facility tour and observation
6.2.76.2.7.1 Scoring of learner assessment instrument is designed and conducted by qualified personnel and following training and education industry accepted practicesPersonnel can be staff, consultants or volunteers.

Qualified personnel means that their training, education and experiences are aligned with their certificate program responsibilities.

Certificate issuer must include a reference or references to support their practices
Certificate program plan, resumes, training log, brochures, website, formal meeting summaries / minutes, assessment instruments

Personnel interviews.
If possible, observe scoring event or have scoring explained by responsible individual
6.2.7.2 Scoring of assessment instrument methods is appropriate for and consistent with program purpose, scope and learning outcomesRationale for scoring mechanism(s) must be provided Certificate program plan, policy manual, formal meeting summaries / minutes, assessment instruments, complaints related to scoring
6.2.7.3 Scoring of assessment instrument is based on a criterion-referenced passing standard in advance of instrument administrationRefer to criterion-referenced passing standard definition in Section 3: Terminology.Certificate program plan, meeting summary, passing standard process report
6.2.7.4 Scoring of assessment instrument is guided by answers keys, rubrics or other scoring guidesDocumentation must be provided on how consistency of scoring is achieved across examiners and administrationsCertificate program plan, scoring guides
Record sampling of scored assessments
6.2.7.4 (1) Learner feedback is considered in finalizing answer keys or rubrics.Certificate issuer must document the feedback process.Feedback forms, records of learner complaintsRecord sampling of complaint records and feedback forms
6.2.86.2.8.1 Results of learner assessment is communicated to participants in consistent, timely and appropriate mannerProcedures must include the timeline and modality for communicating resultsCertificate program plan, policies, procedures, score reports and associated cover letters
6.2.8.2 Results of learner assessment is documented in learner recordsCertificate program plan, policies, procedures

Record sampling review of learner records
6.2.96.2.9.1 Certificate issuer adheres to its own uniform system or chosen organization’s system of measuring and granting creditsIf the certificate issuer does not issue academic or continuing education credits, these requirements do not apply.Certificate program plan, brochures or other promotions, approval by outside organization (e.g., IACET)
6.2.9.2 In advance of the program, certificate issuer determines and publishes type and quantity of credits granted and their requirementsMeeting summary, brochures or other promotions, documentation supplied to outside organization
6.2.106.2.10 Comprehensive evaluation is conducted on a regular basisThis refers to the program evaluation which includes, but is not limited to, program requisites, intended learning outcomes, learning event, learner assessment instrument performance, etc. What is evaluated depends upon the organization’s documented performance expectations.

The minimum evaluation timing is not identified by the standard because of the high variability of certificate program length. If a program runs multiple times throughout a year, an annual evaluation would be expected unless rationale is provided.
Certificate program plan, formal meeting summaries/minutes, calendar of programming, evaluation plan, assessment reports
6.2.10.1 Program evaluation measures quality, effectiveness and value of program against stated performance expectationsCertificate program plan, formal meeting summaries/minutes, evaluation plan, assessment reports
6.2.10.2 (1) Individual conducting learner assessment and/or learner assessment instrument performance is monitored for patterns/trendsCertificate program plan, formal meeting summaries/minutes, evaluation plan, assessment reports
6.2.10.2 (2)Methods/instruments are monitored by oversight committee to verify linkage to and measurement of learning outcomesCertificate program plan, formal meeting summaries/minutes, evaluation plan, assessment reports
6.2.10.3 Primary stakeholders are given opportunity to provide feedback on program design, content, delivery and learner assessment(s)Program plan, policies or procedures, formal meeting summaries / minutes, assessment reports, feedback sheetsMeet with a group of stakeholders
6.2.10.4 Mechanisms are deployed to regularly monitor and identify need to change program purpose, scope or learning outcomes and to make revisions needed in timely mannerProgram plan, policies or procedures, formal meeting summaries / minutes, internal communications, assessment reports Validate any changes to the program that may be observable
7 Requirements for Certificate Issuance and Use
7.1.17.1.1 Certificate is issued to all certificate holdersProgram plan, policies or procedures

Record sampling review of certificate holder files
7.1.1.1 Certificate is issued only after verification that all requisites are fulfilledProgram plan, policies or procedures

Personnel interviews

Record sampling review of certificate holder files
7.1.1.2 Decision to issue certificate is made solely on information gathered through the certificate program processProgram plan, policies or procedures
Personnel interviews

Record sampling review of certificate holder files
7.1.1.3 Certificate is issued to an individual and is not transferableProgram plan, policies or procedures
7.1.1.4 Certificate is signed or authorized by designated authority and includes certificate holder name, program title and scope, certificate issuer name, designation and associated acronym (if applicable), and issue date and term of validityRefer to term of validity definition in Section 3: Terminology.

Exception: If the term of validity is “for life” then this term does not need to be included on the certificate.
Review of certificate to ensure that information listed under (1) through (5) is on the certificateDocument review of sample certificate

Record sampling review of certificate holder files
7.1.1.5 Certificates are invalidated only if person found to have not fulfilled program requisitesExamples of reasons for invalidation include misrepresentation and cheating.Program plan, policies or procedures

Record sampling review of candidate/certificate holder files
7.1.27.1.2 Designation granted does not include words “certified,” “certificated,” “licensed,”, “registered,” or “accredited,” or imply such statusesIf the certificate issuer does not grant a designation or associated acronym, 7.1.2.1 does not apply; however, 7.1.2.2 does still apply since it covers conditions for use of the certificate.Program plan, policies or procedures, brochures or promotional materials, candidate/certificate holder communications
7.1.2.1 There is an appropriate system to track and monitor designation/acronym use by certificate holdersProgram plan, policies or procedures, certificate holder communications, monitoring reports or communications
7.1.2.2 Certificate issuer documents, manages and communicates conditions for use of the certificate and any associated designations, acronyms or other marks or logosProgram plan, policies or procedures, certificate holder communications

Recognitions