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:
Academic - 3 policies
Policy Name: 3364-77-06 Transfer of Credit to Graduate Degree
Description: (Reaffirmation of existing policy)
Procedure
Scope: University of Toledo graduate students excluding those enrolled in JD, MD and
PharmD programs
Comment Period: March 23, 2026 - April 23, 2026
Comment on this policy: 3364-77-06
Policy Name: 3364-77-09 Graduate Grades and Grading Policy
Description: (Major Revisions) To identify the grades used for graduate coursework at the University, to establish
how grades are awarded and to assign quality points to these grades.
Procedure
Scope: University of Toledo graduate students excluding those enrolled in JD, MD and
PharmD programs
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-77-09
Policy Name: 3364-77-08 Graduate GPA Replacement Policy
Description: (Minor revisions) outlines when a graduate student repeating a course can petition to have the original
course grade removed from the calculation of their cumulative GPA.
Procedure
Scope: University of Toledo graduate students excluding those enrolled in JD, MD and
PharmD programs
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-77-08
College of Medicine and Life Sciences - 1 policy
Policy Name: 3364-81-04-017-01 Disciplinary Action, Due Process, and Appeals
Description: (Minor revision of existing policy) This policy was revised to clarify how degrees of professional behavior are handled
and how they impact a students grade. Timelines for responses by each party in the
process were aligned and clarified. The revised policy also defines which unprofessional
behaviors are reviewed by the student conduct and ethics committee and how they are
reported. Lastly, this revision states the student conduct and ethics committee produces
are not recommendations but decisions that can be appealed through due process.
Scope: College of Medicine and Life Sciences
Comment Period: Februrary 27, 2026 - March 30, 2026
Comment on this policy: 3364-81-04-017-01
General Administration - 1 policy
Policy Name: 3364-5-18 Purchase of Misbranded and Cultivated-Protein Food Products
Description: (New policy)
Scope: All University of Toledo Campuses
Comment Period: March 23, 2026 - April 23, 2026
Comment on this policy: 3364-5-18
Procurement - 1 policy
Policy Name: 3364-40-15 Procurement Policy
Description: (Major revisions) Approving authority, values, emphasis on contracted over preferred.
Comment Period: March 20, 2026 - April 20, 2026
Scope: All University of Toledo Campuses
Comment on this policy: 3364-40-15
UTMC - 15 policies
Policy Name: 3364-87-10 Professionalism and prohibited disruptive behavior regarding members of
the medical staff
Description: (Minor revisions) Updated Peer Review Committee to Professional Improvement Committee. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-87-10
Policy Name: 3364-87-19 Pharmacy and Therapeutics Committee
Description: (Minor revisions) Clarified and updated committee charter. Pharmacy and Therapeutics Committee is
a medical staff appointed committee. Other minor formatting and grammatical changes..
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-87-19
Policy Name: 3364-100-45-14 Suspected Child Abuse and Neglect
Description: (Major revisions) Updated policy statement to add special security precautions followed when caring
for children admitted for suspected child abuse. Updated procedure for announcing
and reporting events. Removed duplication within the document. Other minor formatting
and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-100-45-14
Policy Name: 3364-100-70-14 Pneumococcal and Influenza Vaccine Standing Orders
Description: (Minor revisions) Adding clarifying document language and updated references. Other minor formatting
and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-100-70-14
Policy Name: 3364-144-02 Endoscope Reprocessing
Description: (Minor revisions) Updated dry equipment time from 10 minutes to 12 minutes using the Dri-Scope AIDtm,
as per the manufacturer’s instruction for use. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-144-02
Policy Name: 3364-135-088 Radiopharmaceutical Administration
Description: (Major revisions) Clarified state requirements related to licensed nuclear medicine technologists credentialing,
and authorized users of radioactive materials. Updated policy to reflect procedural
changes related to reporting, competency, training, and authorized users. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-135-088
Policy Name: 3364-135-044 Extravasations of Contrast
Description: (Minor revisions) Added reference to most current version of the ACR Manual on Contrast Media. Other
minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-135-044
Policy Name: 3364-135-064 MRI Contraindications
Description: (Minor revisions) Clarified implant or foreign body clearance is to be by MR conditional card based
on manufacturer specifications. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-135-064
Policy Name: 3364-135-085 Patient preparation and draping
Description: (Minor revisions) Changed hospital approved detergent/disinfectant to Vendora detergent/disinfectant.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: March 20, 2026 - April 20, 2026
Comment on this policy: 3364-135-085
Policy Name: 3364-101-03-10 Electronic Clinical Services
Description: (Minor revisions) Clarified requirements for use of electronic clinical services. Updated reference
to the Ohio Revised Code, State Medical Board telehealth rules, and standards of care
to meet the same requirements as in-person visits. If any deviations from the policy
exist, this must be escalated to the Privacy Officer or Compliance Department for
review and any necessary follow-up or remediation. Only UTMC approved electronic
clinical services platforms may be used. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: February 27, 2026 - March 30, 2026
Comment on this policy: 3364-101-03-10
Policy Name: 3364-120-70 Search, Seizure and Disposition of Drugs, Weapons and Potentially Harmful
Items
Description: (Minor revision of existing policy) Clarifying detail added to procedural steps.
Scope: University of Toledo Medical Center
Comment Period: February 27, 2026 - March 30, 2026
Comment on this policy: 3364-120-70
Policy Name: 3364-120-83 Patient Visitors
Description: (Minor revision of existing policy) Added verification of visitor identity requirement and clarification of where visitor
belongings are stored while in the unit. Rescinded Radiology Policy 3364-135-152.
Scope: University of Toledo Medical Center
Comment Period: February 27, 2026 - March 30, 2026
Comment on this policy: 3364-120-83
Policy Name: 3364-122-47 Body piercing, subdermal/transdermal/microdermal implants and skin divers
Description: (Minor revision of existing policy) Added detail to sections 5 and 6 related to observation.
Scope: University of Toledo Medical Center
Comment Period: February 27, 2026 - March 30, 2026
Comment on this policy: 3364-122-47
Policy Name: 3364-160-SD-144 Psychiatric Advance Directives
Description: (Minor revision of existing policy)
Scope: University of Toledo Medical Center
Comment Period: February 27, 2026 - March 30, 2026
Comment on this policy: 3364-160-SD-144
Policy Name: 3364-120-54-001 Electroconvulsive Therapy (ECT)
Description: (Minor revision of existing policy)
Scope: University of Toledo Medical Center
Comment Period: February 27, 2026 - March 30, 2026
Comment on this policy: 3364-120-54-001