University Policy

Policies Posted for Comment

Draft and recently signed policies are posted here for review and comment by The University of Toledo community for thirty days. Draft policies do not have official status as approved policies until the Approving Officer has signed the policies. Some policies may be signed in advance of the vetting period to comply with the requirement of federal or state laws or regulations or accrediting agencies.

Please direct any comments or questions regarding the policies posted for comment to policies@utoledo.edu or click on the icon under "comment on this policy." Please state the name of the policy in the subject line. Comments received on the policy will be forwarded to the policy's responsible agent or agent's designee.

To join our mailing list for email notification of updates and additions to the Policies Posted for Comment, please send an email to policies@utoledo.edu with "policies posted for comment" in the subject line.

NOTE:  The University’s policies ultimately become a part of the Ohio Administrative Code.  The Administrative Code is written in lower case.  As each UT policy comes due for review, it will be formatted according to the Ohio Legislative Service Commission Drafting Manual.  Many words that normally would be capitalized will not be capitalized in the text of the policy.  For example – university of Toledo, president of the United States, supreme court, holidays such as Christmas day (Christmas is capitalized but day is not).  The Drafting Manual includes many other grammatical guidelines.  The header box and the signature box do not need to comply with these rules.  Please do not send comments asking to revise capitalization, outline format, grammar, etc.    

The following policies have been posted for the 30-day comment period:

College of Medicine & Life Sciences - 6 policies

Policy Name: 3364-81-04-011-01 COMLS Educational Program Objectives Policy
Description: (Minor Revision of Existing Policy) Revisions due to requirements.
Scope: College of Medicine & Life Sciences M.D. Program
Comment Period: October 17, 2025 - November 17, 2025
Comment on this policy: 3364-81-04-011-01

Policy Name: 3364-86-018-00 Moonlighting
Description: (Minor Revision of Existing Policy) Updated to match requirements on J-1 physicians ability to moonlight.
Scope: College of Medicine and Life Sciences
Comment Period: October 17, 2025 - November 17, 2025
Comment on this policy: 3364-86-018-00

Policy Name: 3364-019-00 GME: Resident Eligibility for Graduate Medical Education at The University of Toledo
Description: (Minor Revision of Existing Policy) Removed testing requirement for eligibility in residency program. Change in residency requirements in the Department of Dentistry.
Scope: College of Medicine and Life Sciences
Comment Period: October 17, 2025 - November 17, 2025
Comment on this policy: 3364-019-00

Policy Name: 3364—86-011-00 GME: Completion Certificates
Description: (Minor Revision of Existing Policy) Added completion certificates will be issued to residents and fellows who have satisfactorily completed the required periods of training in their residency or fellowship programs. Removed the resident will be issued a certificate stating “served as” when he/she has performed in a satisfactory manner but did not remain in the program for the duration of time needed to complete board eligibility.
Scope: College of Medicine and Life Sciences
Comment Period: October 17, 2025 - November 17, 2025
Comment on this policy: 3364—86-011-00

Policy Name: 3364-81-30 Graduate Student Leave
Description: (New Policy)
Scope: College of Medicine M.D. Program
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-81-30

Policy Name: 3364-81-31 Professionalism Fellows
Description: (New Policy)
Scope: College of Medicine M.D. Program
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-81-31

Research and Sponsored Programs - 1 policy

Policy Name: 3364-70-22 Principal investigator's responsibilities on sponsored projects
Description: (Major Revision of Existing Policy)
Scope: All University of Toledo Campuses
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-70-22

UTMC - 22 policies

Policy Name: 3364-100-50-16 Management and control of agitated or disturbed persons
Description: (Minor Revision of Existing Policy) Revised Responsible Party and updated telephone numbers.
Scope: The University of Toledo Medical Center 
Comment Period: October 17, 2025 - November 17, 2025
Comment on this policy:  3364-100-50-16

Policy Name: 3364-100-85-02 Visitors/Patients with disabilities using a service animal
Description: (Minor Revision of Existing Policy) Clarified and expanded the role of the service animal handler.
Scope: The University of Toledo Medical Center 
Comment Period: October 17, 2025 - November 17, 2025
Comment on this policy:  3364-100-85-02

Policy Name: 3364-100-50-15 Dissemination of Medical Staff Members, Resident and Allied Health Professional Staff Members Credentialing-Related Information
Description: (Minor Revision of Existing Policy) Updated method of information being disseminated and removed reference to hand delivering urgent information to departments. Updated name of credentialing software and corresponding policy.  Other minor formatting and grammatical changes.
Scope:  University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-50-15

Policy Name: 3364-100-50-44 Warming Devices and Patient Safety
Description: (Minor Revision of Existing Policy) Added 2025 Baxter manufacturer documentation to the policy for reference.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-50-44

Policy Name: 3364-100-70-05 Therapeutic Drug Substitution
Description: (Minor Revision of Existing Policy) Clarified the scope of the committee.  Removed reference to the Pharm Report and policy 3364-133-36.  Added reference to the current procedure for therapeutic drugs substitutions, for all currently approved substitutions.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-70-05

Policy Name: 3364-100-70-10 Medication Management & Responsibility
Description: (Minor Revision of Existing Policy) Updated policy statement to clarify that the licensed practitioner is responsible for medication management within all areas of UTMC.  The policy statement also defines medication management to include ordering, procurement, dispensing, administration, and patient safety.  Under procedure, provided clarification of the different types of orders.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-70-10

Policy Name: 3364-100-70-16 Antimicrobial Stewardship
Description: (Minor Revision of Existing Policy) Updated reference to data selection:  Pain management data will be determined and reviewed by the pain management stewardship subcommittee.  Updated the Pain committee member listing. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-70-16

Policy Name: 3364-100-70-17 Pain Management Stewardship
Description: (Minor Revision of Existing Policy) Updated and clarified that the admission orders will be entered into EPIC by the Admitting Service.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-70-17

Policy Name: 3364-105-135 Coding Productivity/Quality Review Standards
Description: (Minor Revision of Existing Policy) Updated expectations and productivity standards for inpatient coding and outpatient coding. Updated outpatient coding patient types, and patient type acronyms.  Updated language related to productivity/quality monitoring and disciplinary measures.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-105-135

Policy Name: 3364-100-53-25 ED Transitional Admissions
Description: (Minor Revision of Existing Policy) Updated and clarified that the admission orders will be entered into EPIC by the Admitting Service.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-53-25

Policy Name: 3364-109-EQP-305
Description: (Minor Revision of Existing Policy) Updated procedure to clarify when to use, how to use and store ultrasound gel.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-109-EQP-305

Policy Name: 3364-109-GEN-104 Reportable Diseases
Description: (Minor Revision of Existing Policy) Updated references to the Ohio Revised Code tag numbers.  Updated disease listings to current year.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-109-GEN-104

Policy Name: 3364-100-10-09 Consent for Human Immuno-deficiency Virus (HIV) Testing
Description: (Minor Revision of Existing Policy) Updated policy statement and procedure required to obtain consent for HIV screening.  Updated references to the Ohio Revised Code.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-10-09

Policy Name: 3364-134-112 Re-instating Clinical Use After Equipment Repairs
Description: (Major Revision of Existing Policy) Updated policy statement to include equipment repair, maintenance and upgrades will be evaluated by a Qualified Medical Physicist.  The Medical Physicist will provide reference for determination of what will require an evaluation. Procedure updated to clearly indicate evaluation, performance, service, trouble-shooting, and other involvement from biomedical engineering, etc.  Minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-70-22

Policy Name: 3364-142-13 Patient Financial Assistance
Description: (Minor Revision of Existing Policy) Updated policy statement to include UT Employees/dependents and UT Students in addition to Ohio Residents for eligibility of Patient Financial Assistance.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-142-13

Policy Name: 3364-104-206 Nutrition Care ESRD/CLD Scope of Service
Description: (Minor revision of existing policy) Clarified procedure removing reference to patient care programs and monthly rounds.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-104-206

Policy Name: 3364-104-210 Medical Nutrition Order Writing Privileges for Dieticians
Description: (Minor Revision of Existing Policy) Updated references.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-104-210

Policy Name: 3364-104-401 Patient Education
Description: (Minor Revision of Existing Policy) Removed reference to former hospital policy for Accommodations for Patients Who Are Sensory Impaired and/or Who Have Limited Language Proficiency.  Added reference to the new procedure with same title posted to the policy website.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-104-401

Policy Name: 3364-104-609 Relationship with other Departments
Description: (Minor Revision of Existing Policy) Updated committee composition and names of committee groups.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-104-609

Policy Name: 3364-104-403 Scheduling Outpatient Nutrition Consults
Description: (Minor Revision of Existing Policy) Updated the procedure for how to order and schedule nutrition consults.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-104-403

Policy Name: 3364-104-1006 Nutrition Assessment and Intervention of Gastrointestinal-related Cancer Patients with Feeding Tubes
Description: (Minor Revision of Existing Policy) Updated the procedure to remove a step in the notification process for nutrition services order.  The referral will continue to be placed in the outpatient medical record system.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-104-1006

Policy Name: 3364-100-01-25 Addressing Patients
Description: (Minor Revision of Existing Policy) Clarified procedure to add the process for reviewing and documenting patients legal and preferred name in the electronic medical record.  Added reference to Patient Rights policy.  Removed reference to prior medical record systems.  Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 26, 2025 through October 26, 2025
Comment on this policy:  3364-100-01-25