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.

Academic Research - 1 policy
Compliance - 1 policy
Legal Affairs - 1 policy
University Faculty - 1 policy
UTMC - 5 policies


Academic Research - 1 policy

Policy Name:   Draft 3364-70-16  University of Toledo Centers and Institutes 
Description:  (Major revision of existing policy)  The University of Toledo supports and encourages the formation of centers and institutes as a vehicle for faculty, students, and staff to promote an organized program of research, educational, and outreach activities; to advance interdisciplinary activities; to foster multi-institutional, governmental, community and industrial collaborations; and/or to provide unique research and educational experiences for students, faculty, and community members.  Revisions to the policy expand its governance to include the formation and review of both research and non-research centers and institutes.
Scope:   Formation and review of centers and institutes, all campuses
Comment Period:   January 19, 2016 – February 18, 2016
Comment on this policy  3364-70-16


Compliance - 1 policy

Policy Name:   Draft 3364-15-01  HIPAA Organization structure and administrative responsibilities
Description:  (Major revision of existing policy) Under the provisions of the Health Information Portability and Accountability Act (HIPAA), organizations that are subject to HIPAA have certain responsibilities, which are described in this policy. This policy identifies the components of The University of Toledo that are subject to HIPAA, adopts an Affiliated Covered Entity (ACE) status with The University of Toledo Physicians, LLC, describes HIPAA administrative responsibility, and identifies the roles and responsibilities of privacy and security officials within UT.  This policy also describes mandatory training requirements for HIPAA, informs workforce members of HIPAA compliance monitoring, disciplinary action for failure to comply with HIPAA policies and procedures, and sets forth requirements for policies, procedures, documentation and retention.
Scope:    The covered components of The University of Toledo and The University of Toledo Physicians, LLC
Comment Period:   January 25, 2016 –  February 24, 2016
Comment on this policy  3364-15-01


Legal Affairs - 1 policy

Policy Name:   Draft 3364-10-10  Reporting on the job injuries for workers’ compensation purposes
Description:  (Minor/technical revision of existing policy) It is the policy of The University of Toledo that when a university employee has a work related injury or occupational disease, they will seek appropriate medical care, report the injury to their supervisor and complete and submit the injury and illness report form to the workers’ compensation department or their supervisor.  This policy provides direction to the employee and their supervisor on how to assure that an employee with a work related injury or occupational disease receives proper medical care; and submits the documentations that will initiate a workers’ compensation claim when appropriate, and provide information for accident investigation and safety hazard elimination, when appropriate.  Revisions are tracked in the posted draft policy.
Scope:    All University of Toledo campuses
Comment Period:   February 12, 2016 – March 14, 2016
Comment on this policy  3364-10-10


University Faculty - 1 policy

Policy Name:   Draft 3364-72-11 University evaluation of faculty qualifications, including faculty holding less than a master’s degree
Description:  (New policy proposal)  The University of Toledo defines a minimum level of earned degree for course instructors; a minimum threshold of experience for a course instructor who holds less than an earned master’s degree; and establishes an evaluation process for college-specific evaluation for those with less than an earned master’s degree to insure instructors have appropriate qualifications. This policy aligns with requirements adopted by the state of Ohio and by the Higher Learning Commission, the regional accrediting body.
Scope:   This policy applies to all academic colleges, schools, departments and programs at the University
Comment Period:   January 19, 2016 – February 18, 2016
Comment on this policy  3364-72-11


UTMC - 5 policies

Policy Name:   Draft 3364-100-45-02  Request for determination of death by brain criteria 
Description:  (Minor/technical revision of existing policy)  It is the policy to conform with Ohio law and applicable medical practice standards for determination of brain death.  The purpose of the policy is to assure appropriateness of death by brain criteria.  Proposed revisions are red-lined on the posted draft policy.
Scope:   The University of Toledo Medical Center and its Medical Staff
Comment Period:   January 19, 2016 – February 18, 2016
Comment on this policy  3364-100-45-02

Policy Name:   Draft 3364-100-70-07  Ordering of antineoplastic agents 
Description:  (Major revision of existing policy)  All anti-neoplastic orders used to treat cancer must be written for and signed by an appropriate attending physician or hematology/oncology fellow.  He purpose of the policy is to provide guidelines for prescribing chemotherapy and biotherapy used to treat cancer and non-cancerous conditions.  Proposed revisions are red-lined on the posted draft policy.
Scope:   The University of Toledo Medical Center and its Medical Staff
Comment Period:   January 19, 2016 – February 18, 2016
Comment on this policy  3364-100-70-07

Policy Name:   Draft 3364-100-50-30  Hospital-wide discharge planning
Description:  (Major revision of existing policy)  A comprehensive method will be used to provide for the coordination of the patient’s continued care after discharge.  The purpose of the policy is to provide an operational definition of discharge planning, to clarify role responsibility, to outline specific procedures of the disciplines concerned and to document compliance with various regulatory/accrediting bodies.  Revisions are tracked in the posted draft policy.
Scope:    The University of Toledo Medical Center and its medical staff
Comment Period:   February 12, 2016 – March 14, 2016
Comment on this policy  3364-100-50-30

Policy NameDraft 3364-100-53-17  Indications for autopsy
Description:  (Major revision of existing policy) Medical staff members are required to attempt to secure permission to perform autopsies in certain cases.  In all other cases there shall be general guidelines used to identify deaths for which an autopsy is recommended.  Permission to perform an autopsy must be documented and the attending physician must be notified of when the autopsy will be performed.    Revisions are tracked in the posted draft policy.
Scope:    The University of Toledo Medical Center and its medical staff
Comment Period:   February 12, 2016 – March 14, 2016
Comment on this policy  3364-100-53-17

Policy Name:   Draft 3364-100-90-16  Medical record retention and destruction; disposal of protected health information
Description:  (Major revision of existing policy) UT will ensure the privacy and security of protected health information “PHI” in the maintenance, retention and eventual destruction and disposal of such media.  Destruction and disposal of protected health information will be carried out in accordance with federal and state law, and as defined in the university’s retention policy.  The schedule for destruction and disposal shall be suspended for records involved in any open investigation, audit, or litigation.  Revisions are tracked in the posted draft policy.
Scope:    The University of Toledo Medical Center and its health care components, Human Resources, Information Technology
Comment Period:   February 12, 2016 – March 14, 2016
Comment on this policy  3364-100-90-16


Recommendations to Rescind a Policy 

 

Policies recommended for rescission are posted here for comment by The University of Toledo community for thirty days. Please direct any comments or questions regarding the policies recommended for rescission to policies@utoledo.edu

Last Updated: 2/12/16