Contact Person

Document

Amy Harris-Tehan
Plan 48202.002

Revision
Effective Date
Review Date

1
03/15/2014
03/15/2017

DOCUMENT CONTROL PROGRAM PLAN

This plan directs the preparation, review, approval, issuance, availability, and revision of documents
having Laboratory-wide impact.

1.0

APPROVAL RECORD
Reviewed by: Document Control Coordinator (Amy Tehan)
Approved by: Human Resources Manager (Diane Muncrief)
Approved by: Quality Assurance Program Manager (Tom Wessels)
Approved by: Chief Operations Officer (Mark Murphy)
Approved by: Associate Laboratory Director for Sponsored Research (Deb Covey)
Approved by: Assistant Director for Scientific Planning (Cynthia Jenks)
Approved by: Chief Research Officer (Duane Johnson)
Approved by: Interim Deputy Director (David Baldwin)
Approved by: Interim Director (Tom Lograsso)
The official approval record for this document is maintained in the Training, Documents &
Records Office.

2.0

REVISION/REVIEW INFORMATION
The revision description for this document is available from and maintained by the author.

3.0

PURPOSE AND SCOPE

The Ames Laboratory recognizes the importance of documents that prescribe processes,
specify requirements, or establish design. The Document Control (DC) Plan ensures that only
approved, current versions of such documents are used in the workplace or transmitted to
outside entities. This plan directs the preparation, review, approval, issuance, availability, and
revision of documents having Laboratory-wide impact. The level of control for each document is
established according to the complexity and hazards associated with the activities represented
by each document. Documents having Laboratory-wide impact, regardless of origin, shall be
registered and tracked through Document Control as part of the Laboratorys Quality Assurance
Program.
3.1.

Definitions

3.1.1. Lab-wide Documents: Lab-wide documents are those having impact or being used by
the majority of the Ames Laboratory staff population.
3.1.2. Bar code: A unique document identifier generated by records management staff that is
added to the bottom of the first page of some forms and documents that are considered
to be vital records. Bar codes are assigned to documents based on conversations
between records management staff and staff from the documents office of origin.
3.1.3. Vital Records: Records required to meet operational responsibilities or to protect the
legal and financial rights of the Ames Laboratory and its employees during and/or after
an emergency event. The Ames Laboratory maintains four major types of vital records:

Document Control Program Plan

Contact Person
Document

Amy Harris-Tehan
Plan 48202.002

Revision
Effective Date
Review Date

1
03/15/2014
03/15/2017

Official Personnel Files are those records associated with an individuals

employment at the Ames Laboratory. These records are created in the Human
Resources Office.

Employee Medical Records are those records associated with an individuals

medical surveillance at the Ames Laboratory. These records are created in the
Occupational Medicine Office.

Laboratory research notebooks are any form of documentation of research results

funded under the Laboratorys contract with the Department of Energy.

Emergency records are those records essential to continuity of operations and/or

reconstitution of the Ames Laboratory during or after an emergency.

3.1.4. Document Types:

Charter: A document that defines the formal organization of a specialized group at

the Ames Laboratory, and outlines its mission, responsibilities, and goals. These
documents are to have a maximum 5-year revision cycle, and must be approved by
the program director/department manager and all of Executive Council.

Form: A formatted document containing blank fields (spaces) that allow the user to
enter information (text fields, text area fields, drop-down menus, check-boxes, etc.).
These documents are to have a maximum 5-year revision cycle, and must be
reviewed by the program director/department manager.

Guide: A recommended practice that allows some discretion or leeway in its

interpretation, implementation or use. Guidance statements may be included within
other prescriptive documents, but must be noted as such. These documents are to
have a maximum 5-year revision cycle, and must be reviewed by the program
director/department manager.

Handbook: Small scale version of a manual, perhaps focusing on fewer tasks.

These documents are to have a maximum 5-year revision cycle, and must be
reviewed by the program director/department manager.

Handout: A short guidance document providing highlights of a specific plan or

procedure to be used as a quick reference. These documents are to have a
maximum 5-year revision cycle, and must be reviewed by the program
director/department manager.

Manual: Comprehensive, step-by-step directions for a particular task or set of tasks

that serves as a reference book. A manual details what is required, explains how to
put the presented information into practice, and instructs how to solve problems as
they occur. These documents are to have a maximum 3-year revision cycle, and
must be approved by the program director/department manager and the member of
Executive Council having oversight of the originating program area.

Plan: A statement of purpose for future action designed to achieve specific goal(s)
within a specific time frame or in case of an event. A plan explains what needs to be
done, when, how, and by whom. These documents are to have a maximum 3-year
revision cycle, and must be approved by the program director/department manager
and all of Executive Council.

Document Control Program Plan

Contact Person
Document

Amy Harris-Tehan
Plan 48202.002

Revision
Effective Date
Review Date

1
03/15/2014
03/15/2017

Policy: A high level description of required controls for regulating processes. A

policy is a set of declared principles used to direct actions in pursuit of goals and in
preservation of the Lab as an organization. These documents are to have a
maximum 3-year revision cycle, and must be approved by the program
director/department manager and all of Executive Council.

Procedure: Specific actions used to carry out policies and/or plans in the day-to-day
operations of the Laboratory. Procedures may be added to policies or plans as
attachments. These documents are to have a maximum 3-year revision cycle, and
must be approved by the program director/department manager and the member of
Executive Council having oversight of the originating program.

In some instances, it may be difficult or impractical for a document to adhere to only one
document type. There may be plans, policies or manuals that contain procedures or
guidelines. In these cases, the document type should be determined by the author and
Document Control staff.
4.0

ROLES AND RESPONSIBILITIES

4.1.

4.2.

Document Control Staff

Document Control staff are responsible for:

Maintaining a database to track documents having Laboratory-wide impact (DC

staff will also track the internal documents of Laboratory offices or groups upon
request). The database will contain information for each document, including
document type, name and number, author and originating office, effective date,
review date, revision number, and status.

Generating new document numbers upon request, and reminding document

authors of upcoming review dates.

Generating bar codes to be included on vital records.

Overseeing the review, routing and approval of documents. The DC staff work with
document authors, ensuring proper formatting and consistency before requesting
approval.

Providing document development assistance, including creating bookmarked or fillable PDFs.

Coordinating any changes requested by approvers and tracking approval progress.

Maintaining records of document approval, notifying document authors when the

approval process is complete, and requesting that approved documents be posted
online as specified by document authors.

Document Authors
Document authors are responsible for:

Requesting document numbers from Document Control staff and for submitting
documents for approval. Authors are responsible for the content of documents in
accordance with their line management.

Consulting DC staff with any questions regarding document preparation.

Document Control Program Plan

Contact Person
Document

1
03/15/2014
03/15/2017

Providing a Document Submission Form (Form 48202.002) with each new or

revised document.

Adhering to, as much as is practical, the document templates available on the

Ames Lab website when developing or revising documents:
Ames Laboratory Forms and Handouts Template (Form 48202.003)
Ames Laboratory Document Template (Form 48202.004)
Ames Laboratory Document Chapter or Section Template (Form
48202.005)

Maintaining a detailed revision description for all documents with the exception of
forms and handouts. This revision description can be formatted in any way the
author chooses, but changes made in the current revision should be copied and
pasted into the Document Submission Form.

Performing revisions as scheduled or as necessary based on policy or procedure

changes, or regulatory changes.

Notifying affected users when there is a new or revised version of a document.

4.3.

Document Approvers
Approvers are responsible for reviewing, commenting on, and approving documents that
they are requested to approve in a timely manner.

4.4.

Document Users
Document users should be diligent in using the most recent versions of all documents
(do not save local copies of documents). Current versions of frequently used documents
will be available online, and users should refer to these at all times.

PREREQUISITE ACTIONS AND REQUIREMENTS

5.1.

6.0

Revision
Effective Date
Review Date

o
o
o

5.0

Amy Harris-Tehan
Plan 48202.002

Document Planning
Authors shall assess whether new documents will have Laboratory-wide impact.
Document Control staff can assist with this assessment when requested. Documents
having Lab-wide impact must be tracked through the Document Control Program.
Authors of documents not having Lab-wide impact may decide whether they want those
documents tracked through the Document Control Program.

PROGRAM PLAN
The core activities of the Document Control Program are document development, review and
revision, document approval, and document availability and use. A quick reference handout is
available for authors from the Ames Laboratory website.
6.1.

Document Development, Review, Revision, Approval, and Availability

6.1.1. Document Development

Laboratory-wide documents will be developed according to the policies, procedures and
guidelines set forth in this plan. Each document will be assigned a document number
and entered into the DC database. Documents should follow the format set by the
Laboratory's document templates. Authors can use the Ames Laboratory Document

Document Control Program Plan

Contact Person
Document

Amy Harris-Tehan
Plan 48202.002

Revision
Effective Date
Review Date

1
03/15/2014
03/15/2017

Template or the Ames Laboratory Forms and Handouts Template (both can be found on
the Document Control web page) to begin new documents. Each document or form
must be accompanied by a Document Submission Form, and submitted electronically to
[email protected].
All documents, with the exception of forms, guides and handouts, shall begin with an
approval record, followed by revision/review information. Some documents related to
vital records, or containing information that must be preserved or tracked as part of the
Records Management Program, will include a bar code on the bottom right hand corner
of the first page. Authors should contact Document Control staff to determine whether a
form needs a bar code, and to obtain a bar code. Authors must determine whether a
document should be posted online, and instruct the DC Office as such.
Internal documents from Laboratory offices or groups that are tracked through the
Document Control Program shall adhere to the policies and procedures described
above.
6.1.2. Document Review and Revision
All documents must be assigned a review period, as determined by the document type
(see Section 3.1.2, Definitions). The review date must be included in the header for all
documents (with the exception of forms and handouts). When a revision is necessary,
either as a scheduled review or as the result of a regulatory or other change, the
document author must:

Create a new, or add to an existing revision description (forms and handouts do not
require revision descriptions).

Change the version number of the document.

o

For substantial revisions that require approval, and for all scheduled reviews
regardless of the scope of changes, the version number should be changed
in whole numbers (e.g., version 3 to version 4) and the effective date and
next scheduled review date should be updated to reflect the review period.

For minor revisions that do not require approval, the version number should
be changed in decimal increments (e.g., version 3 to version 3.1) along with
the effective date, but the next scheduled review date should not be
changed.

To allow time for routing and approval, post-date the documents effective date two
weeks, and set the effective date at the first or the fifteenth of the month.

Send the revised document, along with the submission form, to

[email protected]. Archive the old version of the document.

Once all materials are gathered and the document has been approved, Document
Control staff will update the database, file the approval paperwork, and post the new
version of the document online (if applicable). The document author will be notified once
this process is complete.
6.1.3. Document Approval
All documents with Laboratory-wide impact must have approval from the appropriate line
management as follows:

Document Control Program Plan

Contact Person
Document

Amy Harris-Tehan
Plan 48202.002

Revision
Effective Date
Review Date

1
03/15/2014
03/15/2017

Policies, charters and plans must be approved by the supervisor or program

manager and all members of Executive Council.
Manuals and procedures must be approved by the program director/department
manager and by the member of Executive Council who has oversight of the
originating office.
Forms, guides and handouts must be reviewed by the supervisor or program
manager.

For minor revisions of policies, plans, manuals, procedures, and handbooks, the
document must be reviewed by the supervisor or program manager. In addition, if a
document lists reviewers on the approval record, the author is responsible for ensuring
that all reviewers have an opportunity to review the document before it is submitted to
Document Control.
The Laboratory's email and shared file systems will be utilized to route and approve
documents.
6.1.4. Document Availability
All policies, plans, manuals, guidelines, handouts, procedures, charters and forms that
are available online must have a document number, and should follow as closely as is
practical the appropriate document format. The file format in which documents are made
available should be determined by the document author and Document Control staff, but
a PDF is the preferred option.
7.0

Post Performance Activity

This program will be assessed every three years at a minimum to ensure the plan is effective,
and that Laboratory employees are aware of, and adhering to the requirements.

8.0

References
Document Control Submission Form (Form 48202.002)
Ames Laboratory Document Template (Form 48202.004)
Ames Laboratory Forms and Handouts Template (Form 48202.003)
Ames Laboratory Document Section or Chapter Template (Form 48202.005)
Guidelines for Lab-wide Document Creation and Revisions (Handout 48202.001)

Document Control Program Plan