Quality Manual: 9.5 Documented Information 9.5.1 Document Management System

QUALITY MANUAL
Revision No.: 01
Effective Date: June 2020
9.5 DOCUMENTED INFORMATION
9.5.1 DOCUMENT MANAGEMENT SYSTEM

POLICY
Unilab Foundation has established, maintained and improved the documented QMS to ensure that
the document control system shall cover only documents and data related to the requirements of ISO
9001:2015 Standards and Requirements.
The documented QMS of the organization consists of the following:
1. Quality Manual - defines the general policies and deployment of the clauses of the ISO 9001:
2015 standards and requirements
2. Procedures - describes how activities specific to particular departments are performed.
3. Records- documents that provide objective evidences of activities performed or results
achieved.
4. Other Quality Supporting Documents contain controlled documents such as Job Descriptions,
and externally generated documents used as reference, if any.
UFI’s documents shall be classified as controlled and uncontrolled.
Controlled document refers to written references which are updated, amended, reviewed and
approved prior to issuance and distribution to internal stakeholders, specifically to the organization’s
personnel. Include internally generated documents such as the Quality Manual, externally-generated
documents such regulatory forms and Unilab Forms adopted by Unilab Foundation and issued for
reference to the organization.
Uncontrolled documents, on the other hand, refer to written references issued and distributed to
external stakeholders which are not required to be amended. Uncontrolled documents are also issued
to process owners requesting for revisions in their respective documents, if necessary.
Prepared by: Reviewed by: Approved by:
MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS
Document and Data Controller Finance , Admin and HR Senior Strategic Support Director Executive Director
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Document and Data Approval & Issuance
Erasures and/or alterations are allowed on documents if the originator affixes signature on top of or
beside the erasure and/or alteration; otherwise, the document (i.e. filled-out form) is considered
invalid and unauthorized.
A Document and Data Controller (DDC) is officially appointed by Quality Council Chairman (QCC)
and has the overall authority and responsibility of the implementation and sustenance of the
document control system of UNILAB FOUNDATION.
The creation and/or modifications of all controlled documents are prepared, reviewed, and approved
by designated authorized personnel prior to issue and use.
Accomplishing Document Modification / Creation Notice (DMCN) is a methodology implemented

for document control. Contents of the Quality Manual are subject to the approval of QCC and
review of QMR, while other QMS-required documentations are for the review and approval of QMR
and Project Leads.
Only documents from external sources used as references are identified in the Master List of
Controlled Documents (External). Endorsement and maintenance are implemented in accordance
with the appropriate Generic Procedure. The user ensures that only authorized and updated copies
of these documents are endorsed for use.
The user of a particular externally-generated document is indicated in the Master List of Controlled
Documents (External); otherwise, copies are considered unauthorized.
Valid copies of controlled documents are identified as such by means of the colored stamp
"CONTROLLED" marked by the DDC except for the original copy. The original copy is
distinguished by the stamp "ORIGINAL" marked by the DDC as well as the colored organization
logo on the top left of each page.
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No copies of obsolete documents are allowed to continue in circulation and, as such, these are
withdrawn immediately from circulation and properly disposed after being replaced by new revisions
or issuances. The original obsolete copies of internally-generated documents are given to the DDC
for archiving along with the DMCN, while obsolete copies of externally-generated documents are
surrendered to the Admin and Finance Officer.
Appropriate documents are made accessible to all personnel concerned at locations where these are
necessary for the effective planning, operation, and control of the Quality Management System.
Documents are to be at the designated work station at all times.
Document and Data Changes
Quality Management System documentations of this manual are made available to users. Creations,
modifications, and/or abolitions of documents follow the appropriate Generic Procedures.
All creations and modifications of controlled documents excluding those on externally-generated

documents are identified and recorded in the DMCN. The nature of change is identified in the
DMCN. Nature of change may be classified as follows:
a. Creation – includes insertion of a new section / subsection, procedure / work

instruction, exhibit / appendix, etc.
b. Modification – includes change in text, insertion of a word / phrase, deletion of a
word / phrase, etc.
c. Abolition – includes deletion of a section / subsection, procedure / work instruction,
exhibit / appendix, etc.
The Master Lists of Controlled Documents identify the current revision status of documents to
preclude the use of obsolete and/or unauthorized documents.
All document modifications drafted are reviewed and signed by the originator and his/her
department head. Accomplishing Document Modification / Creation Notice (DMCN) is a control
methodology implemented for this purpose. Contents of the Quality Manual are subject to the
approval of QCC and review of QMR, while other QMS-required documentations are subject to the
review and approval of QMR and Project Leads.
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Filling-out the obsolete section of the Master Lists of Controlled Documents is a control
methodology which ensures that all obsolete documents are promptly removed from all points of
issue or use as reflected in the Document Modification/Revision Procedure.
The Master Lists of Controlled Documents are independent forms maintained by the DDC. All
modifications made in the controlled documents are reflected on the originator’s draft attached to
the DMCN as well as the obsolete original copy.
The current revision status of documents is established and identified. This is recorded on the
Master List of Controlled Documents (Internal) and DMCN.
APPENDIX
1.0 DOCUMENT CREATION PROCEDURE
ACTIVITY PERSON RESPONSIBLE
1.0 Prepares the draft of the document. Obtains an uncontrolled copy Originator
of the relevant document from the Document Controller, if
necessary.
2.0 Submits the draft to the reviewing authority. Originator
2.1 If staff is the originator, submits the draft to his/her

department head for review
2.2 If department head is the originator, submits draft
directly to the QCC or his/her deputy for review
3.0 Reviews the draft for accuracy and adequacy. Discusses any Originator
changes with Reviewing Authority
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Note: If revisions are required, returns draft to Originator for

modifications, else proceeds to Step 4
4.0 Accomplishes the Document Modification/Creation Notice Originator

(DM/CN) form Originator/Reviewing Authority and submits
the form together with the draft to Document Controller.
Note:
4.1 Effectivity of documents shall be 7 working days upon

receipt of DM/CN form.
4.2 Submission shall be every last working day of the week
5.0 Creates electronically the document based on the agreed format. Document Controller
6.0 Prints and forwards the created document to Originator Document Controller
7.0 Reviews the document for completeness and accuracy and signs Originator
using blue or black ink on the spaces provided for i.e. “ Prepared
by/Date”
7.1 If modification is necessary, returns to Document Controller

for revision, else proceed to Activity No. 8
8.0 Forward the document to the Reviewing Authority Originator
Reviewing Authority
9.0 Reviews the document for accuracy and adequacy. If found in
order, Reviewing Authority signs and dates on the “REVIEWED
BY” portion using blue ink, then submits to the Approving
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Authority and proceeds to Activity No. 10.
Otherwise, discusses additional modification with the Originator

for coordination with the Document Controller.
10. Reviews, approves, signs and dates on the “APPROVED BY” Approving Authority
portion using blue or black ink if found in order, then
proceeds to Activity No. 11.0, otherwise, discusses with the
Reviewing Authority, and/or Originator, and/or Document
Controller.
11. Forwards the approved document to Document Controller Approving Authority
12. Files the created document in the controlled Manual Document Controller
13. Accomplishes the Document Control Logbook/Form Document Controller
14. Files the fully accomplished DCL and the DM/CN form in a Document Controller
separate binder.
15. Notifies all concerned departments of the newly created Document Controller
document through email or if more appropriate, during
OpsCom Meeting.
2.0 DOCUMENT MODIFICATION/REVISION PROCEDURE
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1.0 For complex revisions, prepares the draft of the document using Originator
an uncontrolled copy of the relevant document obtained from
the Document Controller. Otherwise, proceeds to Activity
4.0.==============================]\
2.0
3.0 Submits the draft to the Reviewing Authority. Originator
3.1 If staff is the originator, submits the draft to his/her

department
head for review.
3.2 If department head is the originator, submits draft

directly to the
President and QCC or his/her deputy for review.
4.0 Review the draft for accuracy and adequacy. Discusses any Reviewing Authority
changes with Originator
5.0 Accomplishes the Document Modification/Creation Notice Originator/Reviewing Authority

(DM/CN) form and submits the form together with the draft if
any to Document Controller
Note:
4.1. Effectivity of documents shall be seven (7) working days

upon receipt of DM/CN form.
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4.2. Submission shall be every last working day of the week.
6.0 Retrieves electronically the corresponding file and encodes Document Controller
modification of the document including the effectivity date and
revision no.
Note: All modifications that have been made should be

underlined, when appropriate.
7.0 Prints and forwards the newly revised document to the Document Controller
Originator.
8.0 Reviews modifications as to accuracy and completeness of Originator

content vis-à-vis current document. If found in order, proceeds
to Activity No. 8 other wise discusses with Document Controller
for correction
9.0 Signs and dates on the “Prepared By” portion of the newly Originator
revised document using blue or black ink, then sends document
to Reviewing Authority.
9.1 If staff is the originator, submits the document to his/her

department head for review.
9.2 If department head is the originator, submits the

document directly to the Executive Director/Programs
Director
10.0 Reviews the revised document for accuracy, adequacy, Reviewing Authority
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applicability and possible effect to other implemented procedures

in their area. If found in order, signs and
dates on the “REVIEWED BY” portion using blue ink, then

submits to the Approving Authority and proceeds to Activity
No. 10.0. Otherwise, discusses additional modification with the
Originator for coordination with the Document Controller.
11.0 Reviews, approves, signs and dates on the “APPROVED BY” Approving Authority
portion using blue or black ink if found in order, then proceeds
to Activity No. 11.0. Otherwise, discusses with the Reviewing
Authority and/or Originator, and/or Document Controller.
12.0 Forwards the approved document to the Document Controller. Approving Authority
13.0 Retrieves the obsoleted document in the QMS Manual before Document Controller
filing the newly revised document.
14.0 Stamps “Obsolete” on the obsolete hardcopy document using red Document Controller
ink then indicates in blue or black ink the latest revisions that
supersedes it.
Note: Modifications on the obsolete document shall be identified by

highlighting them with a colored marker.
15.0 Accomplishes the Document Control Logbook/Form (DCL). Document Controller
16.0 Files the fully accomplished DCL/the DM/CN form, and the Document Controller
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original obsolete copy of document in a separate binder
17.0 Notifies all concerned departments of the modified document Document Controller
through email
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3.0 CONTROL OF EXTERNALLY GENERATED DOCUMENTS PROCEDURE
Originator/Document
1.0 Receives/prints a copy of the external document with relevance to
UFI operation such as but not limited to those from government Controller
agencies (DOLE, BIR, SSS, HDMF, Philhealth, City Ordinances or
Resolution), equipment manual, reference and training manuals,
specific circulars and etc.
Document Controller
2.0 Stamps “Received” and / or “External Document” then affix sign
and date of receipt. This shall serve as the original copy of for the
said external document.
Originator/Document
3.0 Records details of external document in the Logbook and in the
Masterlist of Document (External). Controller
NOTE: For proper monitoring, there is a separate logbook for each
type of external document, such as:
⮚ “Masterlist of Equipment Manuals” for reference manuals
used in the operation and maintenance of equipment like
photocopier,ID maker, software and etc.
⮚ “Masterlist of Statutory-Regulatory Reference” for references that
comes from government agencies such as DOLE, BIR,
PHILHEALTH, SSS, PAG-IBIG and other relevant agencies; and
specific circulars as well.
⮚ “Masterlist of Other Institution’s Reference” for references that
come from organizations, institutions, training and seminars’
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materials and the likes which is relevant to UFI operation
Originator/Document
4.0 Arranges the received externally generated document accordingly.
Controller
NOTE: If externally generated document is also available via net,
print out of it is automatically considered uncontrolled document
therefore retrieval is not necessary and user shall be the only liable for
the use of it.
Originator/Document
5.0 Updates list of Masterlist of Document or the Logbook
for any new revision released. Controller
Originator/Document
6.0 Transfers the superseded original document to Archive Center then
apply necessary disposal method accordingly based on the disposal Controller
date.
4.0 REQUEST FOR COPY OF DOCUMENT
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1.0 Receives the approved Document Copy Request (DCR) form, Document Controller
for a particular document.
2.0 Photocopies the requested documents based on the requested Document Controller
quantity.
3.0 Accomplishes completely the form and use DCR as traceability of Document Controller
document receipt.
4.0 Stamps the requested document uncontrolled copy every page. Document Controller
Document Controller
5.0 Releases the requested document and secure signature receipt of Document Controller
requester.
6.0 Files the DCR. Document Controller
9.4.2 RECORD MANAGEMENT SYSTEM

Records Management System (RM) is the systematic control over the creation, maintenance, and use of
information, records, and disposition of records.
Records are a vital asset to:
⮚ provide evidence of activities, actions, consultations and decisions and precedents to funding bodies;
⮚ provide evidence of actions and decisions and precedents for future decision making;
⮚ deliver relevant information to members in an efficient, fair and equitable manner
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RM System ensures that records are created, preserved, and disposed in accordance with established systems
and standards, so that:
* productivity of persons involved in record-keeping and processing is improved
* information-dependent interests of the foundation are safeguarded
* costs associated with record-keeping and disposal are reduced to a minimum
* litigation and legislative / regulatory requirements are complied with
Elements of the Records Management System
1. Record Retention Schedule
RECORDS RETENTION SCHEDULES contain the foundation’s record series with the
corresponding retention periods (how long they should be kept) and disposal specification or
method (i.e., destroy, shred, etc.) per department / unit duly approved by management.
A listing of Records Retention Schedules is a binding document that governs the regular
disposition of records and is created not to deliberately destroy unfavorable documented
evidence prior to litigation or government investigation. Any changes on the Records
Retention Schedule, fully documented and justified, can be made only after reappraisal of the
foundation.
The established retention periods are based on the defined values of the records series. These
record series values are operating, fiscal, legal and historical / research.
Responsibilities of the Users:

1.1 Determine the records title as well as the function / subject and purpose of the record.
1.2 Check the definition of the record series corresponding to the RRS code in the Definition of
Records Series Titles . Compare the definition with the function / subject and purpose of
the record. If the same, proceed to Activity 4.0. If not, proceed to the next activity.
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1.3 Determine under which classification the record belongs and identify the corresponding RRS
code.
Note: AAA.XX refers to the alphanumeric reference of the RRS code where; AAA-
Department (e.g., ADM – Administration, HR - Human Resources), XX-Sequential
Numbering
1.4 Once the RRS code of the record has been identified, look in the Records Retention
Schedule corresponding to the RRS code and identify the following:
- retention period (active and inactive)
- disposal method
2. Definition of Record Series Title contain descriptions of the records series per department in terms of
primary, secondary, and tertiary classifications as applicable.
Primary Classification refers to the basic functions of the organization.
Secondary Classification refers to the next level breakdown of record series. Retention period may
be assigned at this level of classification. It is defined by a numeric code which defines its
hierarchical position relating to and after the primary classification.
Tertiary Classification refers to the most specific category under which records can be filed. It is
identified by a numeric code which defines its hierarchical position relating to and after the secondary
classification.
3. Files Management (Labeling)

To provide users with a detailed procedure on how to implement the Records Retention Schedule,
how to determine present status of files, and how to label files properly
3.1 Records Review
i. Review all contents of the folder/binder
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ii. Check if the folder/binder title fits the filed records

iii. Change the folder/binder title on exchange if title does not match
3.2 Records classification
i. Determine the RRS code and retention period of the files.
3.3 Computation of dates for records
b. Determine the creation /coverage/date of the records in the folder/binder
c. Observe subject, case or project files cut-off
d. Compute for the following using the active and inactive retention periods as determined in
Activity 2.2.
i. Date of transfer to inactive record area=after (end of coverage date+ active retention
period)
Note: This formula applied if the record has an inactive retention period. Those
records without inactive retention period automatically do not have a date of transfer;
a hyphen shall be used instead.
ii. Disposal date= after (date of coverage + active retention period + inactive retention
period)
e. Record sorting
i. Separate active records from the obsolete and inactive records.
ii. For obsolete files and inactive files, refer to subsection 4. Records Turnover and
disposal
iii. For active files, refer to Files Labeling
f. Files Labeling
For paper files, identification and labelling is necessary to maintain physical control over
current files as well as manage growth of new files. Labelling serves as a visual aid by
identifying individual record series and by identifying folders within each series.
For electronic files, identification and labelling is necessary to maintain intellectual control over
current files as well as to manage growth of new files. Labelling serves as an access tool which
allows records to be retrieved in an efficient manner.
When working with paper files three levels of file identification and labelling help simplify and
facilitate filing and retrieval:
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● drawer or shelf labels

● file guide labels (guide cards)
● file folder labels
Labels should be typed in uppercase and include:
● primary classification
● secondary classification (record series)
● dates
File guides serve as "signposts" to lead the searcher to specific portions of the file. Guides may
be used within a drawer to highlight a primary classification, to identify a record series, to
highlight a specific year, or may be used within a record series to identify portions of the file as
required.
Type labels in uppercase and show:
● primary classification (as appropriate)

● secondary classification (record series)
File Folder Labels
● file code (if used) or full record series title

● folder title
● date(s), usually inclusive dates, of the file contents
Electronic Files
Electronic files follow many of the same file identification and labelling guidelines as paper
files. Records are organized by directories which act as the primary classification. Each
directory contains folders which act as record series. Finally, each folder contains individual
documents whose names should represent their subject matter.
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4. Records Turnover and Disposal
a. Records Turnover- systematic transfer of inactive records from the office area to inactive area
records.
Responsibilities of Document and Data Controller:
1.0 Review all records to be turned over to the inactive records area based on the Records
Retention Schedule and file labels.
2.0 Separate and get inactive records from the filing cabinets, racks, or shelves.
3.0 Group together all inactive records.
4.0 Transfer all inactive records to the designated inactive records area.
5.0 Prepare Records Turnover Schedule and Disposal Authorization (RTSDA). (See
Reference Documents)
5.1 Write Name of the Department.
5.2 Write Box Number.
5.3 Write Disposal Date.
5.4 List down all the record titles and date of coverage as they appear in the box.
5.5 Print and sign name under “Prepared by”. Write date RTSDA was prepared.
6.0 Prepare File Box Label. (See Reference Documents)
6.1 Write Name of Owner – Department, except File Location Code.
6.2 Write Box Number.
6.3 Write Disposal Date.
7.0 Request the Department Head to print and sign name in the space for “Approved
by” and write the date the RTSDA was approved.
8.0 Check file box contents against RTSDA. If all records are listed in the RTSDA,
print and sign name in the space provided for “Received and Checked by”. Write
the date when records were received and checked. If there are records missing,
reconcile the RTSDA versus box content.
9.0 Transfer the file box to the Inactive Records Area.
10.0 Write the File Location Code on the RTSDA for transferred inactive records.
11.0 Write the File Location Code in the File Box Label as indicated in the RTSDA.
12.0 File the RTSDA.
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Note:
Initial implementation requires the preparation of a Master List of Quality Records

for Inactive Files so as to facilitate the segregation of active from inactive files. Succeeding
transfer of files to records center requires the preparation of Records Turnover Schedule and
Disposal Authorization.
b. Record Disposal-guide on how to systematically dispose obsolete records from inactive records
area
1.0 Review all Records Turnover Schedules and Disposal Authorization of all inactive
records. If the disposal of a record (or set of records) indicated in any of the
mentioned forms is already due based on the Disposal Date, route the respective
Records Turnover Schedule and Disposal Authorization to the Department
Head / Owner for approval. Otherwise, no activity follows.
2.0 Department Head/Record Owner shall approve disposal of the respective records
by affixing signature on the Records Turnover Schedule and Disposal
Authorization and submit to Overall Records Coordinator.
3.0 Receive Records Turnover Schedule and Disposal Authorization and check each
record’s disposal method in Annex A.
4.0 Dispose records approved for disposal using the prescribed disposal method and
accomplish the Certificate of Disposal portion of the Records Turnover Schedule
and Disposal Authorization Form.
5. Charge out Procedure for Active Records
Charge out procedure is a systematic filing and retrieving active records located at the office area
i. Inform the DDC for required records.
ii. Refer to Master List of Records for the record or file title and corresponding
location and retrieve the record/file from the cabinet.
iii. Accomplish the "Charge Out Log Book".
iv. Charge Out Logbook contains Record File Name, , user’s name, and the date the
file was removed from the file and signature of user/requestor.
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Annex:
A. RECORD RETENTION SCHEDULE
RRS CODE RECORD SERIES TITLE RETENTION PERIOD DISPOSITION
ACTIVE INACTIVE
10 years or until
ACC 1.0 Check Voucher Package 1 year Shred
audited by BIR
10 years or until
ACC 2.0 Check Voucher (2nd copy) 1 year Shred
audited by BIR
10 years or until
ACC 3.0 BIR 2307 Receiving copy 1 year Shred
audited by BIR
10 years or until
ACC 4.0 Check Cutting Summary 1 year Shred
audited by BIR
Journal Vouchers Package 1 year 10 years or until Shred

ACC 5.0
audited by BIR
1 year 10 years or until

ACC 6.0 Financial Report (FS) Shred
audited by BIR
5.1 Monthly
5.2 Annual (Audited)
10 years or until
ACC 7.0 Budget Documents 1 year Shred
audited by BIR
ACC 8.0 Payroll Report 1 year 10 years or until Shred
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audited by BIR
10 years or until
ACC 9.0 Statutory Reports 1 year Shred
audited by BIR
9.1 SSS
9.2 PhilHealth
9.3 Pag-ibig
9.4 BIR
9.5 SEC 243
10 years or until
ACC 10.0 Check Register 1 year Shred
audited by BIR
ACC 11.0 Archive Documents N/A N/A N/A
ACC 12.0 Feedback form 1 year N/A Shred
Official Receipts (VAT and 10 years or until

ACC 13.0 1 year Shred
NON-VAT) audited by BIR
10 years or until
ACC 14.0 Acknowledgment Receipt 1 year Shred
audited by BIR
10 years or until
ACC 15.0 Certificate of Donation 2 years Shred
audited by BIR
ADM 1.0 Request for Food/Venue 1 Year N/A Shred
ADM 2.0 Request for Office Supplies 1 Year N/A Shred
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and Project Collaterals
ADM 3.0 Request for New Line 1 Year N/A Shred
ADM 4.0 Request for Data Plan 1 Year N/A Shred
10 years or until
ADM 5.0 Purchase Order (3rd Copy) 1 year Shred
audited by BIR
Request for Land

ADM 6.0 1 Year N/A Shred
Transportation
Request for Plane Ticket and

Hotel Accommodation
2.1 Ticket
2.2 Hotel
Information Technology
Request Form (ITRF)
Approved Donation Request

Form
Request for Printing and

Mailing
ADM 11.0 Equipment Check Out Form 1 Year N/A Shred
Correspondence
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8.1 Transmittal Memo
8.2 Documents In/Out

Logbook
8.3 Visitors Logbook
8.4 Letters/Solicitations
ADM 13.0 Archive Documents N/A N/A N/A
ADM 14.0 Inventory Report/Stock Card 1 year N/A Shred
Until employee is part

ADM 15.0 Asset Accountability Form N/A Shred
of the Foundation
ADM 16.0 Feedback form 1 year N/A Shred
Scan / transfer to
ADM 17.0 Supplier Evaluation Form 2 years N/A Admin9.0 then
shred
Scan / transfer to
ADM 18.0 Supplier Records 2 years N/A Admin9.0 then
shred
COM 1.0 Communications Toolkit Until Foundation exists Delete/Shred
1.1 ULF Programs Message

Until Foundation exists
House
1.2 ULF and Programs Brand

Until Foundation exists
Key
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1.3 ULF Brand Bible Until Foundation exists
Until Foundation
COM 2.0 Annual Report 1 year Delete/Shred
exists
Until Foundation
COM 3.0 Stakeholder Update 1 year Shred
exists
Move to 13.0
COM 4.0 Media Files Until Foundation exists 2 years
archive
6.1 Photos
6.2 Videos
Move to 13.0
COM 5.0 ULF Reference Files 2 years 6 months
archive
7.1 Corporate Profile
7.2 ULF Intro Deck
7.3 ULF Intro Video
7.4 Program Intro Deck
7.5 Program Intro Video
COM 6.0 Supplier Documents 1 year Shred
9.1 Contracts Duration of contract
9.2 Certificate of Completion Duration of contract
COM 7.0 Work in Progress (WIP) 6 months 6 months Delete
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Move to 13.0
COM 8.0 Media Monitoring 1 year 1 year
archive
COM 13.0 Communications Archive Until Foundation exists Delete/Shred
PPACCV Forms 6 months 6 months Delete
5 years after
Entire duration of employee’s Scan/transfer to
HRD 1.0 201File
employee’s engagement separation from Admin9.0 / Shred
ULF
1.1 Resume’/CV
1.2 Interview Feedback sheet
1.3 Job Offer
1.4 Letter of Appointment

(for regular/probation
employee)/Employment
Contract (for project
employee)
1.5 Pre-employment
requirements
1.6 Performance
Development Plan
1.7 Other Personnel Related

Documents
LEG 1.0 Articles of Incorporation Until foundation exists N/A N/A
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LEG 2.0 By-Laws Until foundation exists N/A N/A
LEG 3.0 BIR Registration Until foundation exists N/A N/A
Scan and transfer

LEG 4.0 Business Permit 1 year N/A to Admin13.0 then
shred
Scan and transfer

LEG 5.0 Barangay Clearance 1 year N/A to Admin13.0 then
shred
Scan and transfer

Depends on the to Admin13.0
LEG 6.0 Contracts duration of the N/A
contract
6.1 Consultancy Contract
6.2 Lease Contract
6.3 Contract with Contractor
LEG 7.0 BOD Minutes of Meeting Until foundation exists N/A N/A
SEC Certificate of
LEG 8.0 Until foundation exists N/A N/A
Registration
DSWD Certificate of
Regsitration
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PCNC Certificate of
Accreditation
BIR Certification as Donee

LEG Until foundation exists N/A N/A
Institution
OPJ 1.0 Minutes Project Duration 3 years Shred
Saved to CD – 2
OPJ 2.0 Emails Project Duration Shred
years
Company
OPJ 3.0 Photos Project Duration Shred/Delete
existence
Company
OPJ 4.0 Videos Project Duration Shred/Delete
existence
Company
OPJ 5.0 Soundbytes Project Duration Shred/Delete
existence
Scan & Destroy

OPJ 6.0 MOA / MOU Life of Agreement N/A
hard copy
Scan & Destroy

OPJ 7.0 Service Agreements Life of Agreement N/A
hard copy
Scan & Destroy

OPJ 8.0 Waivers Life of Event N/A
hard copy
OPJ 9.0 Budget Project Duration 2 years Shred/Delete
OPJ 10.0 GANTT Project Duration 2 years Shred/Delete
OPJ 11.0 BOSCARD Project Duration 2 years Shred/Delete
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OPJ 12.0 Status Trackers Project Duration 2 years Shred/Delete
OPJ 13.0 Activity Sheets Project Duration 2 years Shred/Delete
OPJ 14.0 Correspondences Project Duration 2 years Shred/Delete
OPJ 15.0 Nomination Project Duration 2 years Shred/Delete
OPJ 16.0 Application Forms Project Duration 2 years Shred/Delete
Shred/Delete
OPJ 17.0 Profile Project Duration 2 years
17.1 Profile – PWDs Project Duration 2 years Shred/Delete
17.2 Profile – Accredited

Project Duration 5 years Shred/Delete
Contractors
Scan & Destroy

17.3 Profile – UFLJ Doctors Project Duration N/A
hard copy
OPJ 18.0 Floor Plans Project Duration 2 years Shred/Delete
OPJ 19.0 Structural Plans Project Duration 2 years Shred/Delete
OPJ 20.0 Screenings Project Duration 2 years Shred/Delete
OPJ 21.0 Rating Sheets Project Duration 2 years Shred/Delete
OPJ 22.0 Presentation Decks Latest update 1 year Shred/Delete
OPJ 23.0 Project Manual Latest update 2 years Shred/Delete
OPJ 24.0 Pre- and Post-test Project Duration 2 years Shred/Delete
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OPJ 25.0 Mechanics Project Duration 1 year Shred/Delete
OPJ 26.0 Score Sheet Project Duration 1 year Shred/Delete
OPJ 27.0 Registration Sheet Project Duration 1 year Shred/Delete
QMS 1.0 Quality Manual Until Foundation exists NA
QMS 2.0 Position Description Manual Until Foundation exists NA
QMS 3.0 Record Description Manual Until Foundation exists NA
QMS 4.0 Position Description Manual Until Foundation exists NA
Scan and transfer

QMS 5.0 Obsolete Documents 1 year 2 years to Admin13.0 then
shred
Scan and transfer

Document Modification
QMS 6.0 1 year 2 years to Admin13.0 then
Creation Notice Form
shred
Scan and transfer

QMS 7.0 IQA Checklist 1 year 2 years to Admin13.0 then
shred
Scan and transfer

QMS 8.0 Corrective Action Report 1 year 2 years to Admin13.0 then
shred
Scan and transfer

QMS 9.0 References 1 year 2 years to Admin13.0 then
shred
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Scan and transfer

QMS 10.0 Masterlist of Records 1 year 2 years to Admin13.0 then
shred
B. DEFINITION OF RECORD SERIES TITLE
RECORD SERIES TITLE DEFINITION OF RECORD SERIES TITLE

C. RRS
CODE
Contains the paid Check Voucher and all

supporting documents depending on the nature
ACC 1.0 Check Voucher Package of expense/disbursement as documented in the
Finance Procedures and Work Instructions
which has Check Voucher as reference
ACC 2.0 Check Voucher (2nd copy) Contains the 2nd copy of the Check Voucher
Contains receiving copy from the supplier of

ACC 3.0 BIR 2307 Receiving copy
the BIR 2307 forms
ACC 4.0 Check Cutting Summary Contains Check Cutting Summary documents
ACC 5.0 Journal Vouchers Package Contains the Journal Vouchers and all the
necessary supporting documents as
documented in the Procedures and Work
Instructions which has Journal Voucher as
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reference
ACC 6.0 Financial Report (FS)
6.1 Monthly Contains monthly financial report
6.2 Annual (Audited) Contains audited financial report with ITR
ACC 7.0 Budget Documents Contains Approved Annual Budget
Contains the payroll reports as provided by

ACC 8.0 Payroll Report
Unilab payroll on a monthly basis
Statutory reports containing the required

ACC 9.0 Statutory Reports
forms , proof of filing and payment, if any
9.1 SSS
9.2 PhilHealth
9.3 Pag-ibig
Contains all required BIR reports filed on a

monthly, quarterly and annual basis as
9.4 BIR documented in the Procedures and Work
Instructions “Procedures on Statutory
Reporting”
9.5 SEC
ACC 10.0 Check Register Logbook containing details of the released

checks such as CV No., Check No., Collecting
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agent name, date of check pick-up, etc.
ACC 11.0 Archive Documents Contains archived files
ACC 12.0 Feedback form Contains the feedback of the Stakeholders

Official Receipts (VAT and
ACC 13.0 Contains Accounting copy of Official Receipts
NON-VAT)
ACC 14.0 Acknowledgment Receipt Contains Accounting copy of Official Receipts
Contains ULF copy of Certificate of Donation

ACC 15.0 Certificate of Donation
received by BIR
ADM 1.0 Request for Food/Venue Contains a list of requested food/venue
Request for Office Supplies and
ADM 2.0 Contains a list of requested supplies
Project Collaterals
Contains a list of requested new phone

ADM 3.0 Request for New Line
line/landline
ADM 4.0 Request for Data Plan Contains a list of requested data plan
Contains List of Purchased Items as

ADM 5.0 Purchase Order documented in the Purchase Order, Approved
Quotation and request forms
Contains details of transportation request such

ADM 6.0 Request for Transportation as name of requestor, purpose, destination,
time, date, instructions
ADM 7.0 Request for Plane Ticket and Contains a list of requested plane ticket and
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Hotel Accommodation hotel accommodation
Information Technology Contains a list of requested Information

ADM 8.0
Request Form (ITRF) Technology item
ADM 9.0 SDI/Donation Request Form Contains Approved Request Letter
Request for Printing and Contains a list of requested printouts and

ADM 10.0
Mailing mailing
Contains a list of equipment brought out of the

ADM 11.0 Equipment Check Out Form
office
Contains copies of all communication

ADM 12.0 Correspondence
correspondence
8.1 Transmittal Memo
8.2 Documents In/Out

Logbook
8.3 Visitors Logbook
8.4 Letters/Solicitations
Contains all inactive documents and archive

ADM 13.0 Archive Documents
files
ADM 14.0 Inventory Report/Stock Card Contains inventory of all supplies
ADM 15.0 Asset Accountability Form Contains list of all equipment assignees
ADM 16.0 Feedback form Contains the feedback information from the
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Stakeholders
ADM 17.0 Supplier Evaluation Contains completed supplier evaluation forms
Contains supplier accreditation documentation

ADM 18.0 Supplier Records
requirements
Documents containing Foundation’s and its

COM 1.0 Communications Toolkit programs’ key messages, personality, and
branding guidelines.
1.1 ULF and programs Message
House
1.2 ULF and programs Brand

Key
1.3 ULF Brand Bible
A yearly report issued by the Foundation,

COM 2.0 Annual Report which gives an account of its internal workings
and finances
A monthly update distributed to Unilab’s

COM 3.0 Stakeholder Update internal stakeholders (i.e. owners, board
members)
Media Files A compilation of photos and videos from

COM 4.0 Foundation events, presentations, and other
related occasions
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6.1 Photos
6.2 Videos
Materials that contain information about the

COM 5.0 About ULF Files Foundation and its programs, usually shared
with external audiences.
7.1 Corporate Profile
7.2 ULF Intro Deck
7.3 ULF Intro Video
7.4 Program Intro Deck
7.5 Program Intro Video
COM 6.0 Supplier Documents
Approved agreements with suppliers reflecting

9.1 Contracts
the details, duration, and cost of projects.
Proof of supplier’s completion of deliverables

9.2 Certificate of Completion based in the contracts; required for billing
purposes.
A written record of proceedings and agreement

COM 7.0 Work in Progress (WIP)
during regular Comms meeting.
COM 8.0 Media Monitoring Documentation of articles/features about the
Foundation on print, online and broadcast
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media
An accumulation of historical records related to

COM 9.0 Communications Archive
the Communications function
Documents that contains and tracks request for

COM 10.0 PPACCV Forms communications support from the
Foundation’s programs.
Contains list of all relevant employee

HRD 1.0 201 File
information and records
1.1 Resume’/CV
1.2 Interview Feedback sheet
1.3 Job Offer
1.4 Letter of Appointment (for

regular/probation
employee)/Employment
Contract (for project employee)
1.5 Pre-employment
requirements
1.6 Performance Development

Plan
1.7 Other Personnel Related

Documents
LEG 1.0 Articles of Incorporation Contains Articles of Incorporation and all
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amendments
LEG 2.0 By-Laws Contains By-Laws and all amendments
Contains all registration and permits issued to

LEG 3.0 Registration and Permits the company including SSS, Mayors Permit,
SEC, BIR, PhilHealth, Pag-Ibig
Statutory Reports Contains monthly report of contributions with
LEG 4.0
SSS, PhilHealth, Pag-Ibig
4.1 SSS
4.2 PhilHealth
4.3 Pag-Ibig
Contains the withholding taxes declaration

LEG 5.0 BIR Reports including taxes withheld on compensation,
taxes withheld with suppliers
Contains all the contracts between the company

LEG 6.0 Contracts
and external organization
6.1 Consultancy Contract
6.2 Lease Contract
6.3 Contract with Contractor
LEG 7.0 BOD Minutes of Meeting Contains BOD Minutes of Meeting

LEG 8.0 SEC Certificate of Registration Certificate issued by Securities and and
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Exchange Commission
DSWD Certificate of Certificate of Registration from DSWD as

LEG 9.0
Registration Resource Agency
PCNC Certificate of Certificate from PCNC as accredited Donee

LEG 10.0
Accreditation Institution
Contains discussions, agreements, and action

OPJ 1.0 Minutes
points from internal and external meetings
Electronic communications between project

OPJ 2.0 Emails
officers and their internal and external contacts
Photographic documentation of events and

OPJ 3.0 Photos
activities of all Unilab Foundation projects
Video documentation of events and activities of

OPJ 4.0 Videos
all Unilab Foundation Projects
Audio documentation of events and activities

OPJ 5.0 Soundbytes
of all Unilab Foundation Projects
Notarized legal agreements between ULF and

OPJ 6.0 MOA / MOU
External Partners
Notarized legal agreements between ULF and

OPJ 7.0 Service Agreements
Service Providers
OPJ 8.0 Waivers Legal instruments of UFLJ participants
evidencing the intentional relinquishing or
abandoning of a known right, claim, or
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privilege
Documents showing the amount of money that

OPJ 9.0 Budget is available for, required for, or assigned to a
particular project
Charts illustrating the project schedules of the

OPJ 10.0 GANTT
different ULF projects
Planning tools of the different project officers,

OPJ 11.0 BOSCARD
used to gain approval for new projects
Documents that monitors the weekly progress

OPJ 12.0 Status Trackers
of activities of the project
Detailed list of activities used in implementing

OPJ 13.0 Activity Sheets
project objectives
Written/Printed communication from ULF to

OPJ 14.0 Correspondences
external contacts
Forms used by Nominators to

OPJ 15.0 Nomination Forms endorse/nominate Medical Professionals to the
UFLJ
Forms filled in by Medical Professionals who

OPJ 16.0 Application Forms
have been nominated to the UFLJ
OPJ 17.0 Profile
17.1 Profile - PWDs Basic information sheet of participants in the
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Project : Inclusion Study
Documentation on previously completed

17.2 Profile – Accredited projects, company background and history,
Contractors proof of legal identity (e.g. business permits,
SEC registration, etc.)
Detailed Profile of Medical Professionals who

17.3 Profile – UFLJ Doctors
have gone through the UFLJ (alumni)
A scaled diagram of the layout of a hospital play

OPJ 18.0 Floor Plans
space
Working drawings that provide cross-sectional

OPJ 19.0 Structural Plans views and details of the structural components
of a hospital play space
Documentation of individual ratings given by a

OPJ 20.0 Screenings
screening panel to applicants of the UFLJ
Documentation of individual ratings given by a

OPJ 21.0 Rating Sheets
screening panel to applicants of the UFLJ
PowerPoint presentations prepared by project

OPJ 22.0 Presentation Decks
officers describing their specific projects
Written and compiled processes and

OPJ 23.0 Project Manual
procedures for a completed pilot project
OPJ 24.0 Pre- and Post-test Documentation of survey questionnaires
accomplished by students before and after the
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HSOTG exhibit
Printed and illustrated information about the

OPJ 25.0 Mechanics contest, i.e. eligibility, judging criteria, prizes,
usage rights and responsibilities
Documentation of individual scores given by

OPJ 26.0 Score Sheet judges to contestants of the HSOTG On-the-
Spot Poster Making Contest
Basic information sheet of contestants of the

OPJ 27.0 Registration Sheet
HSOTG On-the-Spot Poster Making Contest
Defines the general policies and deployment of

the clauses of the ISO 9001:2008 Standard,
QMS 1.0 Quality Manual including documented statements of the quality
policy and quality objectives
Describes how activities—either generic for all

Procedures and Work personnel or specific to particular sections—are
QMS 2.0
Instruction Manual performed to ensure the effective planning,
operation, and control of processes
QMS 5.0 Obsolete Documents
Document Modification
QMS 6.0
Creation Notice Form
QMS 7.0 IQA Checklist
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QMS 8.0 Corrective Action Report
QMS 9.0 References
QMS 10.0 Masterlist of Records
Masterlist of Controlled
QMS 11.0
Documents (Internal)
QMS 12.0 Revision History
Masterlist of Controlled
QMS 13.0
Documents (External)
QMS 14.0 IQA Report
QMS 15.0 DMCN Log
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Quality Manual: 9.5 Documented Information 9.5.1 Document Management System

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QUALITY MANUAL

9.5 DOCUMENTED INFORMATION

9.5.1 DOCUMENT MANAGEMENT SYSTEM

UFI’s documents shall be classified as controlled and uncontrolled.

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

Document and Data Approval & Issuance

Accomplishing Document Modification / Creation Notice (DMCN) is a methodology implemented

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

Document and Data Changes

All creations and modifications of controlled documents excluding those on externally-generated

a. Creation – includes insertion of a new section / subsection, procedure / work

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

1.0 DOCUMENT CREATION PROCEDURE

ACTIVITY PERSON RESPONSIBLE

2.0 Submits the draft to the reviewing authority. Originator

2.1 If staff is the originator, submits the draft to his/her

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

Note: If revisions are required, returns draft to Originator for

4.0 Accomplishes the Document Modification/Creation Notice Originator

4.1 Effectivity of documents shall be 7 working days upon

7.1 If modification is necessary, returns to Document Controller

8.0 Forward the document to the Reviewing Authority Originator

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

Authority and proceeds to Activity No. 10.

Otherwise, discusses additional modification with the Originator

11. Forwards the approved document to Document Controller Approving Authority

13. Accomplishes the Document Control Logbook/Form Document Controller

2.0 DOCUMENT MODIFICATION/REVISION PROCEDURE

ACTIVITY PERSON RESPONSIBLE

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

3.0 Submits the draft to the Reviewing Authority. Originator

3.1 If staff is the originator, submits the draft to his/her

head for review.

3.2 If department head is the originator, submits draft

President and QCC or his/her deputy for review.

5.0 Accomplishes the Document Modification/Creation Notice Originator/Reviewing Authority

4.1. Effectivity of documents shall be seven (7) working days

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

4.2. Submission shall be every last working day of the week.

Note: All modifications that have been made should be

8.0 Reviews modifications as to accuracy and completeness of Originator

9.1 If staff is the originator, submits the document to his/her

9.2 If department head is the originator, submits the

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

applicability and possible effect to other implemented procedures

dates on the “REVIEWED BY” portion using blue ink, then

Note: Modifications on the obsolete document shall be identified by

15.0 Accomplishes the Document Control Logbook/Form (DCL). Document Controller

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

original obsolete copy of document in a separate binder

Prepared by: Reviewed by: Approved by:

MEL L. COTEJAR MARVIN O. CESARIO HAZEL ANICETO ELIZABETH C. ARISTORENAS

3.0 CONTROL OF EXTERNALLY GENERATED DOCUMENTS PROCEDURE