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.


College of Medicine and Life Sciences - 3 policies
Compliance -2 policies
Facilities and Construction - 1 policy
Hospital Administration - 8 policies
Human Resources and Talent Development - 11 policies
Policies for rescission - 8 policies
Student Life - 4 policies
University Faculty - 1 policy
University Inclusiveness - 1 policy


College of Medicine and Life Sciences - 2 policies

Policy Name:   Recently Signed 3364-81-04-015-02 Travel support for medical student research presentations
Description:  (Minor/technical revision of existing policy) Medical students are encouraged to report results of their research, with faculty sponsors as co-authors of publications, at institutional, local, regional, and national meetings.  This policy outlines the requirements, procedures, and limits for institutional travel support for research or other approved scholarly presentations.
Scope:    College of Medicine & Life Sciences M.D. Program
Comment Period:   August 17, 2017 – September 18, 2017
Comment on this policy  3364-81-04-015-02

Policy Name:   Recently Signed 3364-81-04-025-00 Separation of Roles
Description:  (Minor/technical revision of existing policy) In accordance with LCME Standards, it is essential to have a separation of roles among academic advisors to ensure confidentiality and absence of conflict of interest in medical student promotion and evaluation decisions.  Therefore, students should have options to obtain advice about academic issues or academic counseling from individuals who have no role in making promotion or evaluation decisions.
Scope:    College of Medicine & Life Sciences M.D. Program
Comment Period:   August 17, 2017 – September 18, 2017
Comment on this policy  3364-81-04-025-00


Compliance - 2 policies

Policy Name:   Draft 3364-15-11 Government Inquiries and Investigations Involving UTMC
Description:  (Minor/technical revision of existing policy) UTMC may receive inquiries for information or documents from the Federal and state agencies (“Government Investigators”) or such Government Investigators may appear unannounced at UTMC’s facilities or at the homes of present or former employees for purposes of interviewing and obtaining documents.  Accordingly, this policy serves to establish a mechanism for the orderly response to government investigations to enable the organization to protect its interests while cooperating with any government inquiries and investigations.
Scope: University of Toledo Medical Center and Health Science Campus
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy  3364-15-11

Policy Name:   Draft 3364-15-12 Identify theft detection, prevention, and mitigation
Description:  (Major revision of existing policy)  UT’s identity theft program will detect, prevent, and mitigate identity theft in connection with new and preexisting covered accounts.
Scope:
    All University of Toledo Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy  3364-15-12


Facilities and Construction -  1 policy

Policy Name:   Draft 3364-20-08 Facilities and Construction Operating Policy in Non-Emergency and Emergency Situations
Description:  (New policy proposal) This policy proposal combines 3364-20-01 (Facilities and construction critical utility/life support policy) and 3364-20-02 (Facilities and construction operating policy) into one all-encompassing policy.  The purpose of this new policy is to provide guidance and understanding concerning everyday operating procedures within facilities and construction as it may relate to faculty and staff in other departments.  To create and maintain a safe and secure environment for patients, visitors, faculty, and staff during any natural or unnatural disaster, or during any utility/equipment loss.
Scope:    All University of Toledo Campuses
Comment Period:   August 18, 2017 – September 18, 2017
Comment on this policy  3364-20-08


Hospital Administration - 8 policies

Policy Name:   Draft 3364-100-01-02 Leave of absence for patients
Description:  (Minor/technical revision of existing policy) The purpose of this policy is to provide an avenue of communication and establish a uniform procedure between the patient, physician, and Nursing Administration concerning a leave of absence.  Revisions were made to (C) Procedure.
Scope:    The University of Toledo Medical Center
Comment Period:   July 28, 2017 – August 28, 2017
Comment on this policy  3364-100-01-02

Policy Name:   Draft 3364-100-01-17 Access to Care
Description:  (Major revision of existing policy) The purpose of this policy is to maximize patient throughput, prevent delays in admissions, or cancellations of planned procedures.  Revisions were made to (C) Procedure, specifically Communications and Prioritization of Patient Flow.
Scope: The University of Toledo Medical Center
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-100-01-17

Policy Name:   Draft 3364-100-45-06 Code Blue Policy
Description:  (Major revision of existing policy) The purpose of the Code Blue team is to assure the prompt and skilled cardiovascular and cerebral resuscitation of persons who suffer a cardiopulmonary arrest.  Revisions were made to (C) Procedure.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-100-45-06

 Policy Name:   Draft 3364-100-45-09 Blood Transfusion Reaction Protocol
Description:  (Minor/technical revision of existing policy) The purpose of this policy is provide immediate and appropriate treatment of a suspected blood or blood component transfusion reaction.  Revisions were made to (A) Policy Statement and (C) Procedure.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-100-45-09

Policy Name:   Draft 3364-100-45-22 Reporting of Animal Bites
Description:  (Major revision of existing policy) The purpose of this policy is to provide uniform policy for the Emergency Department and clinics to follow in reporting animal bites as required by law.  Revisions were made to (A) Policy Statement and (C) Procedure.
Scope: The University of Toledo Medical Center
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-100-45-22

Policy Name:   Draft 3364-100-53-05 University Protocol Policy-Procedural Verification/Time Out
Description:  (Major revision of existing policy) The purpose of this policy is to ensure patient safety by establishing consistent guidelines for performing PRE-PROCEDURAL VERIFICATION, CORRECT SITE MARKING, and performing a “TIME OUT” for invasive and surgical procedures performed in the Operating Room and in all inpatient and outpatient clinical areas where procedures are performed.  The intent of the policy is to prevent wrong-patient, wrong-site, wrong-procedure surgery/procedures.  Revisions were made to (B) Purpose of Policy and (C) Procedure.
Scope: The University of Toledo Medical Center and its Medical Staff
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-100-53-05

Policy Name:   Draft 3364-100-85-03 Visitor Authorization After Regular Hours
Description:  (Minor/technical revision of existing policy) The purpose of this policy is to maintain a secure environment for patients and staff, by identifying a system when requests are made to visit after regular visiting hours.
Scope:    The University of Toledo Medical Center
Comment Period:   August 17, 2017 – September 18, 2017
Comment on this policy  3364-100-85-03

Policy Name:   Draft 3364-100-01-18 Notification of Hospital Discharge Appeal Rights
Description:  (Major revision of existing policy) The purpose of this policy is to comply with the Centers for Medicare and Medicaid Services (CMS) regular requirements to notify Medicare beneficiaries, who are hospital inpatients, of their hospital discharge rights.
Scope:    The University of Toledo Medical Center
Comment Period:   August 17, 2017 - September 18, 2017
Comment on this policy  3364-100-01-18


Human Resources - 11 policies

Policy Name:   Draft 3364-25-127 Mandatory training
Description:  (New policy proposal)  The purpose of the policy is to offer compliant and standardized training on Federal/State regulatory programs.
Scope:    All University of Toledo Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy  3364-25-127

Policy Name:   Draft 3364-25-01 Standards of conduct
Description:  (Minor/technical revision of existing policy) Changed responsible agent to AVP of HRTD and Provost.
Scope: The University of Toledo – All Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-25-01

Policy Name:   Draft 3364-25-44 Independent contractor status
Description:  (Major revision of existing policy) The purpose of this policy is to provide guidance for proper determination of independent contractor status for those providing services to the University.
Scope: The University of Toledo – All Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-25-44

Policy Name:   Recently signed 3364-25-47 Criminal background check
Description:  (Major revision of existing policy) The University will conduct criminal background checks on all final candidates hired for faculty, staff, contingent, temporary, resident, volunteer, and select graduate and undergraduate student employment positions as part of the hiring process.
Scope: Final candidates hired or rehired for faculty, staff, contingent, temporary, resident, volunteer, and select graduate and undergraduate student positions as part of the hiring process on all University of Toledo campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-25-47

Policy Name:   Draft 3364-25-65 Consensual romantic and/or sexual relationships
Description:  (Major revision of existing policy) The purpose of this policy is to explain the University’s position on consensual romantic and/or sexual relationships among and between its faculty, staff, students, residents, interns, and fellows.
Scope: The University of Toledo – All Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-25-65

Policy Name:   Draft 3364-25-104 Drug-free workplace
Description:  (Minor/technical revision of existing policy) Renamed from “Drug and alcohol testing” and added procedure 3364-25-104.1 and 3364-25-104.2.
Scope: The University of Toledo – All Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-25-104

Policy Name:   Draft 3364-25-105 Drug and alcohol abuse
Description:  (Minor/technical revision of existing policy) Changed Scope to “The University of Toledo – All campuses” and added procedure 3364-25-105.1.
Scope: The University of Toledo – All Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-25-105

Policy Name:   Draft 3364-25-114 Wage increases – non-contract employees
Description:  (Minor/technical revision of existing policy) Changed Scope to “The University of Toledo – All hourly, non-bargaining employees, All Campuses”.
Scope: The University of Toledo – All hourly, non-bargaining employees, All Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-25-114

Policy Name:   Draft 3364-25-126 Reporting of absences
Description:  (Minor/technical revision of existing policy) Removed “UTMC physician” as a requirement to return to work.  This policy was combined with 3364-25-122 Attendance (HSC), which is now recommended for rescission.
Scope: The University of Toledo – All Campuses (non-faculty)
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-25-126

Policy Name:   Draft 3364-25-27 Retirement program
Description:  (Minor/technical revision of existing policy) This policy describes retirement programs and services that may be available to employees who retire from the University.  Public employees within the state of Ohio participate in a retirement program with eligibility and conditions of retirement as prescribed by the Ohio Revised Code.  Changes were made to Section (D) The University of Toledo retirement programs and services.
Scope:    The University of Toledo – All Campuses
Comment Period:   August 18, 2017 – September 18, 2017
Comment on this policy  3364-25-27

Policy Name:   Draft 3364-25-111 Corrective action (non-collective bargaining unit employees)
Description:  (Minor/technical revision of existing policy) The purpose of this policy is to advise employees or actions or behavior subject to corrective action and procedures.  Disciplinary actions should be imposed with the intent of giving the employee the opportunity to correct his/her behavior.  If such correction does not occur, the level of discipline should become more severe.  Certain offense, by their nature, may warrant more severe disciplinary action up to and including removal, irrespective of issuance of prior discipline.  Changes were made to Section (E) Process.
Scope:    The University of Toledo – All Campuses
Comment Period:   August 18, 2017 – September 18, 2017
Comment on this policy  3364-25-111


Student Life - 4 policies

Policy Name:   Draft 3364-30-04 Student Code of Conduct
Description:  (Major revision of existing policy) Many changes made to all sections of the policy.  Please review attached document.
Scope: All Students of the University of Toledo as set forth in this policy
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-30-04

Policy Name:   Draft 3364-30-20 Policy on hazing
Description:  (Minor/technical revision of existing policy) Revised definition of hazing to be in line with Draft 3364-30-04 Student Code of Conduct.
Scope: All University of Toledo Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-30-20

Policy Name:   Draft 3364-30-22 University Behavior Intervention Team
Description:  (Minor/technical revision of existing policy) Revised the name to University Behavior Intervention Team from Student Behavior Review Committee and revised areas of (C) Procedure.
Scope: The University of Toledo – All Campuses
Comment Period:   August 1, 2017 – August 31, 2017
Comment on this policy:  3364-30-22

Policy Name:   Draft 3364-30-54 Mandatory Tuberculosis (TB) Screening of Students from World Health Organization-Designated High TB Prevalence Countries
Description:  (New policy proposal) Currently numbered 3364-81-04-030, this policy will now apply to all University students from Affected Countries.  Incoming students with a suspicion of active TB, with a positive symptom screen and/or abnormal x-ray suspicious or active TB, will be referred for immediate UT specialist consultation for evaluation.  Students with active TB should expected to be isolated and treated.
Scope: All Students from Affected Countries
Comment Period:   August 22, 2017 – September 21, 2017
Comment on this policy:  3364-30-54


University Faculty - 1 policy

Policy Name:   Draft 3364-72-14 Teaching by non-faculty employees
Description:  (New policy proposal) The purpose of this policy is to define the criteria under which non-faculty employees are permitted to teach.
Scope: Teaching by UT employees not holding faculty rank
Comment Period:   August 11, 2017 – September 11, 2017
Comment on this policy:  3364-72-14


University Inclusiveness - 1 policy

Policy Name:   Draft 3364-50-01 The University of Toledo’s Title IX policy
Description:  (Major revision of existing policy) The University seeks, through this policy, to acknowledge and comply with its duties under federal and state laws and set forth a comprehensive framework for receiving, processing, investigating, and resolving complaints of sexual misconduct.  This policy also provides the University community with necessary information regarding how to make complaints, receive assistance and support, and what to expect from the investigation process.
Scope:    All University of Toledo Campuses
Comment Period:   August 15, 2017 - September 14, 2017
Comment on this policy  3364-50-01


Policies for rescission

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

3364-25-21 Early learning center (day care) (This policy is a department procedure and is presented to parents directly by the Early Learning Center.)
Comment Period:   August 1, 2017 – August 31, 2017

3364-25-26 Leave of absence without pay (Policy merged with 3364-25-123 Leaves of absence (other than FMLA) & sick leave HSC.)
Comment Period:   August 1, 2017 – August 31, 2017

3364-25-106  Drug and alcohol testing-HSC (Policy changed to procedure associated with 3364-25-105 Drug and Alcohol abuse.)
Comment Period:   August 1, 2017 – August 31, 2017

3364-25-122  Attendance and absence from premises-HSC (Policy combined with 3364-25-126 Reporting of absences)
Comment Period:   August 1, 2017 – August 31, 2017

3364-25-125  Sick Leave (Policy combined with 3364-25-123 Leaves of absence (other than FMLA) & sick leave HSC.) 
Comment Period:   August 1, 2017 – August 31, 2017

3364-20-01 Facilities and construction critical utility/life support policy (This policy is being merged with 3364-20-02 to create new policy 3364-20-08 Facilities and Construction Operating Policy in Non-Emergency and Emergency Situations.)
Comment Period: August 18, 2017 – September 18, 2017

3364-20-02 Facilities and construction operating policy (This policy is being merged with 3364-20-01 to create new policy 3364-20-08 Facilities and Construction Operating Policy in Non-Emergency and Emergency Situations.)
Comment Period: August 18, 2017 – September 18, 2017

3364-81-04-030 Mandatory Tuberculosis (TB) Screening of Students from World Health Organization-Designated High TB Prevalence Countries  (This policy is being re-numbered to Student Life Policy 3364-30-54 and will apply to all students from affected countries.)
Comment Period: August 22, 2017 – September 21, 2017

Last Updated: 8/22/17