sman1-sumbawabesar qsec27901 fa-sa oct11

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Audit Report

COMMERCIAL- IN – CONFIDENCE

The contents of this report must not be disclosed to a third party without the agreement of the SAI Global Client

DISCLAIMER:

This report has been prepared by SAI Global Limited (SAI Global) in respect of a Client's application for assessment by SAI Global. The purpose of the report is to commentupon evidence of the Client's compliance with the standards or other criteria specified. The content of this report applies only to matters, which were evident to SAI Global at the

time of the audit within the audit scope. SAI Global does not warrant or otherwise comment upon the suitability of the contents of the report or the certificate for any particular purpose or use. SAI Global accepts no liability whatsoever for consequences to, or actions taken by, third parties as a result of or in reliance upon information contained in this

report or certificate.

ACTIVITY ID: 353599

QEF08C.09 / Issue Date: 2009-Jun-05 © SAI Global Limited Copyright 2008 - ABN 67 050 611 642 of 7

App./Cert. QEC27901

Date 25/10/2011

FOLLOW UP AUDIT

Client: SMA Negeri 1 Sumbawa Besar

Site Address: Jl. Garuda No.1, Sumbawa Besar, Nusa Tenggara Barat, Indonesia.

Attn. Mr. Agus Surya Pratama, S.Pd. (Management Representative)

Standard(s): 9001:2008

Relevant Codes (as applicable)

ANZ8422

Scope of Certification:

The registration covers Quality Management System for the provision of senior high schooleducation services.



AUDIT REPORT

ACTIVITY ID: 343128


IntroductionSAI Global conducted an audit of SMA Negeri 1 Sumbawa Besar on 25/10/2011 to 25/10/2011 .The purpose of this audit report is to summarise the degree of compliance with relevant criteria, asdefined on the cover page of this report, based on the evidence obtained during the audit of your

organisation.

SAI Global audits are carried out within the requirements of SAI Global procedures that also reflectthe requirements and guidance provided in the international standards relating to audit practicesuch as ISO/IEC 17021, ISO 19011 and other normative criteria. SAI Global Auditors are assignedto audits according to industry, standard or technical competencies appropriate to the organisationbeing audited. Details of such experience and competency are maintained in our records. Theaudit team is detailed in the attached audit record.

In addition to the information contained in this audit report, SAI Global maintains files for eachclient. These files contain details of organisation size and personnel as well as evidence collectedduring preliminary and subsequent audit activities (Documentation Review and Scope) relevant tothe application for initial and continuing certification of your organisation.

Details of your primary contact persons and their contact details and site addresses are alsomaintained. Please take care to advise us of any change that may affect theapplication/certification or may assist us to keep your contact information up to date, as required bySAI Global Terms and Conditions.

Please note that this report is subject to independent review and approval. Should changes to theoutcomes of this report be necessary as a result of the review, a revised report will be issued andwill supersede this report.

Executive OverviewThere were 2 non-conformances identified during the previous audit therefore the follow-up audithas been conducted by SAI Global for verification. Verification by relevant SAI Global auditor wasperformed through document review and the results were recorded this report.

The verification result shows that the corrective actions taken by the organisation were acceptedtherefore the recommendation to ISO 9001:2008 certification for SMA Negeri 1 Sumbawa Besar could be given.



AUDIT REPORT

ACTIVITY ID: 343128


Audit ObjectiveTo determine that appropriate correction and corrective action has been taken with regard to non-conformance reports issued at a previous audit.

Actions taken on Non-conformance ReportsDuring the Stage-2 Initial Certification Audit to the organisation on 29 July 2011, 2 non-conformance findings were identified as follow:

NCR#01-2011Non-conforming situation:

Customer perception monitoring, internal audit, and management review were noteffectively implemented.Pemantauan persepsi pelanggan, audit internal, dan tinjauan manajemen belum diimplementasikansecara efektif.

Requirement:

ISO 9001:2008 Clause 5.6 Management review; 8.2.1 Customer satisfation; 8.2.2 InternalauditObjective evidence:

• Survey to measure customer perception has been performed to students and parentsbut the survey results were not processed and analysed yet including necessaryimprovement plan.Survey untuk mengukur persepsi pelanggan sudah dilaksanakan terhadap siswa dan orang tuasiswa namun belum ada sama sekali hasil pengolahan dan analisa serta rencana peningkatanyang diperlukan.

• Internal audit was done in proper manner, e.g.: - All root-cause analysis and action plan were defined by the internal auditor

themselves. - All non-conformities were states as closed, where in actual most of them were still

remain open. Audit internal sudah dilakukan namun diamati bahwa pelaksanaannya belum sesuai misalkan:- Semua analisa akar penyebab dan rencana tindakan ditetapkan oleh auditor internal sendiri. - Semua temuan ketidaksesuaian dinyatakan selesai, padahal sebagian besar masih belum

tuntas pada aktualnya.

• Management review has been conducted however it was only cover internal audit resultonly and the minutes only contain the recapitulation of internal audit non-conformityfindings. Tinjauan manajemen telah diselenggarakan namun hanya membahas hasil audit internal sajadan notulennya hanya berisi rekapitulasi temuan ketidaksesuaian internal audit saja.

NCR#02-2011Non-conforming situation:

The most of requirements regarding competence and training was not fullfiled yet.

Persyaratan terkait dengan kompetensi dan pelatihan sebagian besar belum terpenuhi.Requirement:

ISO 9001:2008 Clause 6.2.2 Competence, awareness, and trainingObjective evidence:

• Teacher competency evaluation was not finalized yet whereas the evaluation result wasused as input for development need analysis.Penilaian kompetensi guru belum selesai dilakukan dimana hasil penilaian ini menjadi dasar dalam analisa kebutuhan pengembangan.

• Competency development program based on the priority from competency evaluationresult and as basis for training and education proposal was not established.Program pengembangan kompetensi berdasarkan skala prioritas dari hasil penilaian kompetensi dan juga sebagai dasar untuk usulan diklat belum ada.



AUDIT REPORT

ACTIVITY ID: 343128


• Training and education activity realization record was not availabel. And format for training history was available but last updated in 2008.Catatan pelaksanaan kegiatan diklat belum dilakukan. Sedangkan format riwayat diklat sudahtersedia namun terakhir diperbaharui tahun 2008.

• Mechanism of training and education effectiveness evaluation was not established andimplemented at all.Mekanisme evaluasi keefektifan diklat belum ditetapkan dan diimplementasikan sama sekali.

The organisation has proposed the action plans including root-cause analysis, correction,corrective action, and completion date on 11 August 2011 and it was accepted.

The evidences of follow-up actions were first submitted on 14 October 2011 but it was notsufficient, therefore the auditor has requested additional evidences. All received evidences werereviewed and verified on 25 October 2011.

The results from customer satisfaction survey to evaluate school service and facility and education

process were sighted. The survey results have been recapitulated and analysed, and shows goodsatisfaction level. Internal audit was performed on 8-10 August 2011. The audit non-conformityfindings were recapitulated for status monitoring. Based on the follow-up action records, seems allfindings have been closed. The management review has been conducted on 11 October 2011 andattended by top managemen and all key personnel. Based on the minutes, seems required agendahas been covered.

Teacher competency evaluation has been finalised. Competency development program based onthe priority from competency evaluation result was sighted. Training realization was updated intotraining history record. Training effectiveness evalaution wa conducted.

Based on the verification results, the non-conformance finding could be closed with some notesdefined in the raised areas of concern stated in the report.

Other issues still requiring attentionEffectiveness of follow-up actions taken regarding the non-conformance finding will be re-verifiedon-site during the next audit, and also area of concerns identified during the previous audit (1stsurveillance).

RecommendationThe recommendation from this audit is that your certification proceeds.

Audit recommendations are always subject to ratification by SAI Global certification authority.

This report was prepared by:

Agus Setiawan



ACTIVITY ID: 353599


AUDIT RECORD

All applicable requirements of relevant standards are covered during the audit of the ‘Functions/Processes/Areas.* Enter shift details only where applicable.

Results: = audited no NCR’s, ! = Area of concern to follow up, NCR Nr. for open NCR’s, NCR Nr. (C) - for closedNCR’s, (-) = not fully audited, (blank) = not audited

Audit Team Leader: Agus SetiawanAuditors: NoneObservers/Technical Specialist: None

Total number employees relevant to this audit and site: 80

Applicable Statutory/Regulatory/Standardsrequirements (to be identified by the client):

Ministry of National Education regulationsLocal Government regulations

Exclusions FromStandard Requirements: None

ExclusionsFrom Scope of Certification:

None

Day Auditor Audit meetings plus functions/

processes/ areas/ *shifts audited

Audit areaemployee

no

#Shifts* Result

Tuesday,25/10/2011

pm Agus Setiawan

Verification of corrective actions to non-conformance finding no.NCR#01-2011 andNCR#02-2011

(Document Review / Off-site Audit)

NCR#01-2011 (C)

NCR#02-2011 (C)

pm Agus Setiawan REPORT PREPARATION & SUBMISSION



ACTIVITY ID: 353599


Next audit plan

Audit type: 1st Surveillance Audit

During our next audit the issues identified as requiring attention will be reviewed to ensure they

have been adequately addressed, as well as the following set out in the plan below:

All applicable requirements of the standard including relevant customer specific requirements arecovered during the audit of the ‘Functions/Processes/Areas. The plan is draft and can be modifiedto suit all availability of relevant people.

Date Auditor Audit meetings plus functions/ processes/areas/ shifts audited

# Shift Approx. time

Date tobeplanned/confirmedwith clientbeforeleaving

To beconfirmed

Entry Meeting 9.00am

Management System Support Functions:

- Review of any changes- Management commitment, objectives and targets- Achievements with respect to policy and

objectives- Internal audit, management review processes and

continual improvement, including customer satisfaction

- Customer complaint handling system

- Use of marks and/or any other reference tocertification

am

Actions taken on previous audit issues am

Break am-pm

Human Resources incl. Competence andTraining pm

Library Management pm

Report Preparation/ Debrief 4.00pm



ACTIVITY ID: 353599


Appendix - Definition of and action required with respect to audit findings

Non-conformity:

Based on objective evidence, the absence of, or a significant failure to implement and/or maintain requirements of the applicable standard. Such issues may raise significant doubt as

to the capability of the management system to achieve its intended outputs.

Action required: This category of findings requires SAI Global to issue a formal NCR; to receiveand approve client’s proposed correction and corrective action plans; and formally verify theeffective implementation of planned corrections and corrective action. Correction and correctiveaction plan should be submitted to SAI Global prior to commencement of follow-up activities asrequired. Follow-up action by SAI Global must ‘close out’ the NCR or reduce it to a lesser categorywithin 90 days for initial certification and 60 days for surveillance or recertification audits. If significant risk issues (e.g. safety, environmental, food safety, product legality/quality, etc.) aredetected during an audit these shall be reported immediately to the Client and more immediate or instant correction shall be requested. If this is not agreed and cannot be resolved to the satisfactionof SAI Global, immediate suspension shall be recommended.In the case of initial certification, failure to close out NCR within the time limits means that the

Certification Audit Stage 2 may be repeated.In the case of an already certified client, failure to close out NCR within the time limits means thatsuspension proceedings may be instituted by SAI Global.

Follow-up activities incur additional charges.

Area of Concern:

This is an area of the system for which the client is required to investigate potential non-conformity.

Action required: SAI Global may require client to formulate preventive action plan for approval prior to next planned audit / certification decision or alternatively may follow up client’s preventive actionat the next planned audit. Lack of client attention to such issues implies that a preventive actionsystem is not working effectively.

Opportunity for Improvement:

A documented statement, which may identify areas for improvement however shall not makespecific recommendation(s).

Action required: Client may develop and implement solutions in order to add value to operationsand management systems. SAI Global is not required to follow-up on this category of audit finding.

sman1-sumbawabesar qsec27901 fa-sa oct11

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