University Policy Website

The University of Toledo Policy Website is a compilation of relevant policy, operational procedures, governing documents and handbooks of The University of Toledo. The purpose of the policy website is to ensure faculty, staff, and students have ready access to policies. It is the responsibility of the UT community, including faculty, staff, and students, to familiarize themselves with the policies and comply with the University policies that affect them.

Policy Review and Approval Process

Draft policies are posted on the Policies Posted for Comment page for a thirty day period, during which time the campus community has an opportunity to offer comments or suggestions about the draft policy. Comments submitted for review are answered by the policy’s responsible agent.

An email notification of updates and additions to the Policies Posted for Comment is distributed to all University faculty and staff.

The University of Toledo approves, issues, and maintains policies using a consistent process and format. Please see the 3364-10-01 Formulation and issuance of policies for the standard format, vetting, and approval process for the policies.

The Policy Committee is charged with ensuring that the University’s policies are accessible, appropriately disseminated, and current. The committee does not decide the appropriateness or validity of policies. The committee is comprised of membership from the Provost’s Office, Faculty Senate, Internal Audit and Compliance, Legal Affairs, University Archives, and the UT Medical Center.

Contact Annette Hyttenhove, at annette.hyttenhove@utoledo.edu (419.530.4043) or Assistant General Counsel, Adam Motycka at adam.motycka@utoledo.edu (419.530.8418) for more information about University policies.

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.

College of Medicine and Life Sciences - 1 policy

Policy Name:  3364-81-29 Medical student housing for offsite required clinical clerkship rotations
Description: (New policy)  This policy defines the requirements and expectations for housing accommodations for offsite locations.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-81-29

Academic - 1 policy

Policy Name:  3364-72-12 Administrator assuming a faculty position
Description: (Minor revisions to policy)  The revisions clarify and provide detail to this policy.
Scope: All University of Toledo Campuses
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-72-12

Graduate Medical Education - 3 policies

Policy Name: 3364-86-008-00 Appeal process for all eligible corrective action
Description: (Major revision of policy)  The Resident will request an appeal by emailing the Associate Dean for GME. After submitting the appeal request the Resident has seven (7) calendar days to provide additional documentation supporting their case to the Associate Dean for GME. The Associate Dean for GME or his/her designee will review the information provided on the Corrective Action and the response from the Resident. The Associate Dean for GME will render a summary decision. Removal of Remediation Report and previous Remediation template that is being revised and reduced into three pages.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-86-008-00

Policy Name:  3364-86-026-00 USMLE Step 3 or equivalent examination timing
Description: (Minor/technical revision of existing policy)  Grammar edit – “from another training program” has been removed from a sentence.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-86-026-00

Policy Name:  3364-86-045-00 Semi-annual evaluations
Description: (Minor/technical revision of existing policy)  The semi-annual evaluations are to be completed no later than December 31^st of the academic year, and end of year evaluations are to be completed no later than June 30^th.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-81-29

University of Toledo Medical Center – 11 policies

Policy Name: 3364-100-50-38 Patient safety event including sentinel events
Description: (Major revision of existing policy)  Title updated to include sentinel events policy. Sentinel event definition was updated to include death caused by self-inflicted injurious behavior with new criteria to include while in a health care setting, and within 7-days of discharge from an inpatient, emergency department, behavioral health, day treatment program, partial hospitalization program, residential, group home or transitional supportive living. Under safety reporting, added words upon discovery, prior to the word determination of sentinel event, to clarify when the event support team is initiated.
Scope: The University of Toledo Medical Center and its medical staff
Comment Period: January 31, 2025 through March 3, 2025
Comment on this policy:  3364-100-50-38

Policy Name:  3364-100-45-19 Pediatric patients
Description: (Major revision of existing policy)  Title updated to encompass all pediatric patients. Policy, purpose, and scope changed to Management of pediatric patients in elective surgery and emergency care with definition of pediatric patient, under the age of 16 years. New patient criteria have been added related to eligibility and admission criteria. Pre-operative evaluation and preparation was added. Emergency Department Management evaluation and stabilization added. Transfer for ineligible patients added. Ohio Code added as a reference.
Scope: The University of Toledo Medical Center and its medical staff
Comment Period: January 31, 2025 through March 3, 2025
Comment on this policy:  3364-100-45-19

Policy Name:  3364-100-01-20 Management of UTMC inpatients requiring radiation therapy at the Eleanor N. Dana Cancer Center
Description: (Major revision of existing policy)  Under patient populations, added ICU and Non-ICU patient instructions into the policy. Under procedure, added details about vented patients, how to transport, and with whom should accompany them, to ensure patient safety. Removed all language related to radiation staff responsibility for transport. Added documentation requirements during patient transport to be manually written and scanned into patient record. Added instructions for patients who have a cardiopulmonary arrest during transport and during treatment.
Scope: The University of Toledo Medical Center
Comment Period: January 31, 2025 through March 3, 2025
Comment on this policy:  3364-100-01-20

Policy Name:  3364-100-01-01 Admission, discharge and transfer
Description: (Major revision of existing policy)  Under Intra-Unit and Inter-Unit Transfers, added section on transfer from the intensive care unit to step-down or med-surg units; specifically, transfer instructions for the ICU, Medical ICU and Surgical ICU teams. The ICU team will inform the nurse supervisor of intent to transfer, notify receiving team of pending transfer, provide verbal hand-off; and a written hand-off to the receiving team for patients with ICU stay over 72 hours. Added ICU team responsibility for placing the patient in the primary team list. Added Medical ICU will provide care of transferred patients until 7am the following day. Added the Surgical ICU will provide care until transferred patient can physically leave the unit. Other minor grammatical and formatting changes.
Scope: The University of Toledo Medical Center
Comment Period: January 31, 2025 through March 3, 2025
Comment on this policy:  3364-100-01-01

Policy Name: 3364-100-53-24 Emergency Medical Screening and Transfer
Description: (Minor revision of existing policy)  Under policy statement, added Emergency Medical Screening and Transfer (EMTALA) for reference to regulations. Under procedure, added exempt location clarification. Changed documentation log to Epic Report to document emergency care. Removed attachments due to form changes, updates and/or future updates.
Scope: The University of Toledo Medical Center
Comment Period: February 7, 2025 through March 10, 2025
Comment on this policy:  3364-100-53-24

Policy Name:  3364-100-50-33 Cardiopulmonary resuscitation competency, ACLS and PALS certifications
Description: (Major revision of existing policy)  Changed name of policy to include type of required certifications; ACLS and PALS. Under procedure, added clarification of the acceptable competency training bodies and required frequency for recertification. Provided clarification on continued employment status or job modification if employee is unable to fulfill requirements. Scope: The University of Toledo Medical CenterComment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-100-50-33

Policy Name:  3364-135-056 Nuclear medicine administration
Description: (Minor revision of existing policy)  For clarification, added identifying acronym to Radioisotope Committee (RSC). Under procedure, added requirement for a list of current authorized users and their approved use for medical use radioactive materials. Added resource for questions in the Radiation Safety Office. Added requirements for approval from authorized users, criteria and documentation. Other minor grammatical changes.
Scope: Radiology
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-135-056

Policy Name:  3364-135-091 Radiopharmaceutical administration, oral directive and revisions to written directives
Description: (Minor revision of existing policy)  Under procedure, added requirement for a list of current authorized users and their approved use for medical use radioactive materials. Added resource for questions in the Radiation Safety Office. For clarification, added identifying acronym to Radioisotope Committee (RSC) and Authorized Users (AU). Minor grammatical changes.
Scope: Radiology
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-135-091

Policy Name:  3364-135-092 Radiopharmaceutical medical event
Description: (Minor revision of existing policy) Under procedure, minor grammatical changes, and update to reporting language. Scope: Radiology
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-135-092

Policy Name:  3364-135-136 Quality control of nuclear medicine equipment
Description: (Minor revision of existing policy)  Updated policy statement to include optimal image quality and compliance with regulations involving radioactive materials (RAM). Under purpose of policy added clarification to incorrect prescribed radiopharmaceutical activity and added departments instead of procedures. Under procedures, added criteria for equipment that fails quality checks and required action taken. Changed dose calibrator to dose calibrator systems. Added other testing criteria for equipment and frequency. Added qualitied individuals who may perform preventative maintenance. Added CT to quality check language. Removed section on annual evaluation by a medical physicist.
Scope: Radiology
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-135-136

Policy Name:  3364-100-01-09 Admission and discharge criteria for intensive care units
Description: (Major revision of existing policy)  Under procedure, updated ICU vital sign criteria, clinical and diagnosis related criteria. Added Step down unit responsibility and criteria for respiratory, vital signs and clinical and diagnosis related criteria. Conflict resolution was updated to require discussion for admission and intra-hospital transfers to be held with pulmonary/critical care fellow and attending. Minor structural and grammatical changes.
Scope: The University of Toledo Medical Center and its medical staff
Comment Period: February 14, 2025 through March 17, 2025
Comment on this policy:  3364-100-01-09