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:
Administration - 5 policies
Policy Name: 3364-72-56 Workload
Description: (New Policy)
Scope: University wide
Comment Period: November 4, 2025- December 4, 2025
Comment on this policy: 3364-72-56
Policy Name: 3364-72-57 Faculty Annual Performance Evaluation
Description: (New Policy)
Scope: University Wide
Comment Period: November 4, 2025- December 4, 2025
Comment on this policy: 3364-72-57
Policy Name: 3364-72-58 Post-tenure Review
Description: (New Policy)
Scope: University Wide
Comment Period: November 4, 2025- December 4, 2025
Comment on this policy: 3364-72-58
Policy Name: 3364-72-59 Tenure
Description: (New Policy)
Scope: University Wide
Comment Period: November 4, 2025- December 4, 2025
Comment on this policy: 3364-72-59
Policy Name: 3364-72-60 Retrenchment
Description: (New Policy)
Scope: University Wide
Comment Period: November 4, 2025- December 4, 2025
Comment on this policy: 3364-72-60
College of Medicine & Life Sciences - 4 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
UTMC - 13 policies
Policy Name: 3364-139-1-03 High Level Disinfection (HLD)
Description: (Minor revision of existing policy) Updated policy statement to include Sterile Processing department oversight. Updated
definitions to remove nasal specula, nasopharyngeal endoscopes, laryngoscopes, and
added bronchoscopes. Other minor formatting and grammatical changes.
Comment Period: November 5, 2025 - December 5, 2025
Comment on this policy: 3364-139-1-03
Policy Name: 3364-87-01 Confidentiality and Access to Proceedings and Records of Peer Review Committees
Description: (Minor revision of existing policy) Updated Chairmen to Chairs. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-87-01
Policy Name: 3364-140-30 Transplant Nutrition
Description: (Minor revision of existing policy) Combined 3364-104-207 - Outpatient Nutrition Screening for Recipient and Donor Kidney
Transplant Patient. Updated policy language to include to reflect the new Pancreas/Kidney-Pancreas
program. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-140-30
Policy Name: 3364-87-11 Credentials Committee
Description: (Minor revision of existing policy) Under procedure, removed reference to Appendix A in the Medical Staff Bylaws. Other
minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-87-11
Policy Name: 3364-100-01-03 Patient Transportation to other Health Resources
Description: (Minor revision of existing policy) Clarified process for arranging and charging for transportation. Other minor formatting
and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-100-01-03
Policy Name: 3364-100-10-10 Against Medical Advice: Informed Refusal/Withdrawal of Treatment or
Leaving the Hospital
Description: (Minor revision of existing policy) Updated reference link to Patient Safety Network. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-100-10-10
Policy Name: 3364-100-45-04 Care of Inpatient on Hospice Agency Services
Description: (Minor revision of existing policy) Updated procedure to remove patient personal attire, personal item(s), and visitation
requirements. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-100-45-04
Policy Name: 3364-100-45-22 Reporting of Animal Bites
Description: (Minor revision of existing policy) Updated reference to the Animal Bite reporting form, and how to report animal bites
to the Toledo - Lucas County Health Department. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-100-45-22
Policy Name: 3364-100-45-25 Urgent and Emergent Inpatient Intubation Pathway
Description: (Minor revision of existing policy) Removed reference from Medical Intensive Care Unit (MICU) to Intensive Care Units
(ICU’s). Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-100-45-25
Policy Name: 3364-100-50-08 Hospital Research and Grant Application Process
Description: (Minor revision of existing policy) Removed reference to policy 3364-70-00 and updated to policy 3364-70-22. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-100-50-08
Policy Name: 3364-100-90-19 Social Media
Description: Content of this policy is addressed in other existing policies.
Scope: University of Toledo Medical Center
Comment Period: October 24, 2025 - November 24, 2025
Comment on this policy: 3364-100-90-19
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