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 Affairs - 2 policies
Policy Name: 3364-71-34 Institutional data governance committee
Description: (New policy) Establishes the authority of a formal Data Governance Committee to 1) set data management
principles and standards for the caretaking and use of institutional data, and 2)
assign data stewardship responsibilities for assuring the accuracy, consistency, and
completeness of data.
Scope: All university organizational units working with institutional data
Comment Period: January 30, 2025 - March 02, 2026
Comment on this policy: 3364-71-34
Policy Name: 3364-71-35 Academic Program Review
Description: (New policy) Updated language from Mentally Ill to a Person with Mental per the Ohio Revised Code.
Updated procedure to match current requirements for emergency hospitalization, liability,
and documentation requirements. Other minor formatting and grammatical changes.
Scope: All academic programs
Comment Period: January 30, 2025 - March 02, 2026
Comment on this policy: 3364-71-35
College of Medicine and Life Sciences - 1 policy
Policy Name: 3364-81-04-018-00 The Learning Environment and Faculty Professionalism
Description: (Minor revision of existing policy)
Scope: College of Medicine and Life Sciences
Comment Period: January 30, 2025 - March 02, 2026
Comment on this policy: 3364-81-04-018-00
Compliance
Policy Name: 3364-15-02 Detecting and preventing fraud waste and abuse
Description: (Major revision of an existing policy) Updates include the policy statement, purpose, scope, definitions, whistleblower protections,
consequences, and reporting requirements.
Scope: All University campuses, including vendors and contractors
Comment Period: January 30, 2025 - March 02, 2026
Comment on this policy: 3364-15-02
UTMC - 13 policies
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), administrative
language, and visitation requirements. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 30, 2025 - March 02, 2026
Comment on this policy: 3364-100-45-04
Policy Name: 3364-118-20 Management of HBV and Other Blood Borne Pathogens in the Dialysis Unit-Infection
Control
Description: (Major revision of existing policy) Clarified and provided greater detail overall. Added section (C)(7) - Management
of exposure to HBsAG (+) dialysis patients, as aweel as current reference materials.
Scope: University of Toledo Medical Center
Comment Period: January 30, 2025 - March 02, 2026
Comment on this policy: 3364-118-20
Policy Name: 3364-100-45-23 Involuntary Civil Commitment; Patients Lacking Decision-Making Capacity
Description: (Minor revision of existing policy) Updated language from Mentally Ill to a Person with Mental per the Ohio Revised Code.
Updated procedure to match current requirements for emergency hospitalization, liability,
and documentation requirements. Other minor formatting and grammatical changes.
Exhibit Documentation: DMHAS-0025 Application for Emergent Admission and DMHAS-0030 Affidavit of Mental Illness
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-100-45-23
Policy Name: 3364-124-04 Care of Specimens
Description: (Minor revision of existing policy) Updated Procedure to include that Specimen Disposition will be confirmed with the
attending physician during the procedure sign-out, at the end of the case. Other
minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-124-04
Policy Name: 3364-124-21 Storage of Sterile Supplies
Description: (Minor revision of existing policy) Clarified procedure statement removing temperature requirement for storage of sterile
supplies. Updated procedure to clarify action plan when humidity is out of range.
Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-124-21
Policy Name: 3364-124-66 Tissue Management
Description: (Minor revision of existing policy) Updated to reflect current tracking procedure and how to report through patient safety
net. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-124-66
Policy Name: 3364-135-01 Weight Limits of Imaging Tables
Description: (Minor revision of existing policy) Updated Weight limits of equipment based on manufacturer requirements. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-135-01
Policy Name: 3364-135-029 Timeliness of Critical Findings Reporting
Description: (Minor revision of existing policy) Updated timelines and criteria for notification of critical findings. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-135-029
Policy Name: 3364-135-095 Use of Radiation Protective Apparel when assisting in a procedure
Description: (Minor revision of existing policy) Minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-135-095
Policy Name: 3364-135-163 Pregnancy Screening prior to Nuclear Medicine Therapeutic Procedures
Description: (Minor revision of existing policy) Clarified pregnancy screening process. Updated scope to include timeline and other
relevant criteria. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-135-163
Policy Name: 3364-87-03 Medical Record Delinquency Policy
Description: (Minor revision of existing policy) Clarified expectation for provider signature within 24 hours for operative/procedure
report. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-87-03
Policy Name: 3364-101-109-01 University Counseling Center Billing for Services
Description: (New policy)
Scope: University of Toledo Medical Center
Comment Period: January 16, 2025 - February 16, 2026
Comment on this policy: 3364-101-109-01