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.

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:

College of Medicine & Life Sciences –  1 policy

Policy Name:  3364-81-27 Standing committees – oversight committee
Description:  (Major revision of existing policy)  Major revision to oversight committee structure.
Scope:  College of Medicine & Life Sciences
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-81-27

 

Office of Legal Affairs –  1 policy

Policy Name:  3364-10-17 Minors on campus
Description:  (Major revision of existing policy)  The revisions clarify definitions, update policy exclusions, introduce a new process for exemption requests, and remove some procedures from the policy.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-10-17

 

Human Resources – 6 policies

Policy Name:  3364-25-04 Personnel records
Description:  (Minor revision of existing policy)  The procedure section is being removed, and the policy statement is being retained.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-04

Policy Name:  3364-25-07 New employee orientation
Description:  (Minor revision of existing policy)  Minor changes are being made to clarify the content covered during orientation.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-07

Policy Name:  3364-25-20 Employee assistance program
Description:  (Minor revision of existing policy)  Keywords are being added. The proposal clarifies that EAP services are available at any time.  In addition to voluntary usage, a manager can make a mandatory referral to the EAP service for cause. If a management referral is made, the employer may retain the record confirming participation in the employee file.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-20

Policy Name:  3364-25-27 Retirement program
Description:  (Minor revision of existing policy)  Revisions are being proposed to clarify that participation in a retirement program is required and that full-time employees have up to 120 days to opt into the alternative retirement plan. Additionally, employees cannot change retirement plan elections during their employment.  Employees may request that accrued sick and vacation time payouts be placed into an established tax-deferred voluntary retirement plan, provided they give adequate notice.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-27

Policy Name:  3364-25-32 Voluntary reduction in hours – salaried staff
Description:  (Minor revision of existing policy)  Minor changes are being made to clarify how approvals are given for a voluntary reduction in hours.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-32

Policy Name:  3364-25-112 Working out of classification – HSC
Description:  (Minor revision of existing policy)  Minor changes are being made to the policy language regarding how work may be assigned.
Scope:  The University of Toledo-All Campuses; classified hourly employees not covered by a collective bargaining agreement
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-112

The following policy is effective immediately and is posted for the 30-day comment period:

Policy Name:  3364-25-67 Workplace violence
Description:  (Minor revision of existing policy)  To create a campus-wide task force to address antisemitism, Islamophobia and anti-Christian issues, add (f) under section (E)(2) that states the following, verbatim from SB 94:
(f) Serves as a campus task force on combating antisemitism, Islamophobia, anti-Christian discrimination, and hatred, harassment, bullying, or violence toward others on the basis of their actual religious identity or what is assumed to be their religious identity at the institution.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-67

The following policies have been proposed to be rescinded and are posted for the 30-day comment period:

Human Resources – 3 policies

Policy Name:  3364-25-34 Conflicts with collective bargaining agreements
Description:  Rescission of this policy is recommended. Ohio law and the university collective bargaining agreements address the content of this policy.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-34

Policy Name:  3364-25-37 Flexible spending account plan
Description:  Rescission of this policy is recommended. Employee benefit information is available on the Total Rewards website.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-2537

Policy Name:  3364-25-38 Insurance – health, life, and disability; travel accident coverage; dental, optical, and prescription drug coverage
Description:  Rescission of this policy is recommended. Employee benefit information is available on the Total Rewards website.
Scope:  All University of Toledo Campuses
Comment Period:    July 25, 2025 through August 25, 2025
Comment on this policy:  3364-25-38

University of Toledo Medical Center – 26 policies

Policy Name:  3364-101-06-05 Prescription refills
Description:  (Major revision to policy) Under scope, updated process for prescription refills to include authorization, scope of clinic and medical staff.  Clarified emergent situations in which verbal orders would be appropriate.  Other minor grammatical and formatting changes.
Scope:  Ambulatory Services
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-101-06-05

Policy Name:  3364-100-53-06 Legal medical record
Description:  (Minor revision to policy) Under procedure, updated documentation removed reference to clinical portal and added electronic medical record.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-100-53-06

Policy Name:  3364-100-50-25 Care of patient belongings and valuables
Description:  (Minor revision to policy)   Under procedure, updated the process for patient belongings and valuables to be documented upon admission, and at discharge in the medical record.  Updated process and location for holding belongings and valuables, and the timeframe in which they will be held.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-100-50-25

Policy Name:  3364-100-50-38 Patient safety event including sentinel events
Description:  (Minor revision to policy)  Under procedure, updated the Sentinel Event definition based on new regulatory accreditation requirement from the Joint Commission.  Other minor grammatical and formatting changes. 
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-100-50-38

Policy Name:  3364-100-01-11 Regional access - transfers
Description:  (Minor revision to policy)   Updated procedure to include changes in communication on transfers from Admission Coordinator to Transfer Center.  Updated physician response time for return call from two-three minutes to thirty minutes.  Updated process for documentation.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-100-01-11

Policy Name:  3364-131-05 Home infusion care
Description:  (Major revision to policy)   Updated policy purpose to provide a standardized approach for coordination of care for discharging patients in need of Home Infusion Therapy, ensuring continuity of care.  Updated the procedure to clarify the admission assessment, documentation, benefits, financial information, and involvement of the multidisciplinary team.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-131-05

Policy Name:  3364-131-09 Discharge prescriptions assistance
Description:  (Major revision to policy)   Updated policy purpose to provide a standardized approach for coordination of care of discharging patients in need of prescription medication assistance, ensuring continuity of care.  Updated the procedure to clarify the admission assessment, documentation, financial information, and involvement of the multidisciplinary team.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-131-09

Policy Name:  3364-131-14 Non-medical transportation services
Description:  (Minor revision to policy)   Updated policy purpose to provide a standardized approach for coordination of care of discharging patients in need of non-medical transportation, ensuring continuity of care.  Updated the procedure to clarify the admission assessment, documentation, benefits, financial information, and involvement of the multidisciplinary team.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-131-14

Policy Name:  3364-131-06 Durable medical equipment
Description:  (Minor revision to policy)   Updated policy purpose to provide a standardized approach for coordination of care for discharging patients in need of durable medical equipment, ensuring continuity of care.  Updated the procedure to clarify the admission assessment, documentation, benefits, financial information, and involvement of the multidisciplinary team.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-131-06

Policy Name:  3364-133-14 Pharmaceutical representatives
Description:  (Minor revision to policy)   Updated procedure to clarify UTMC Vendor Identification Permit requirements, and location for Pharmaceutical Representatives to report.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-133-14

Policy Name:  3364-141-03 Trauma admission names
Description:  (Minor revision to policy)   Updated policy statement and procedure to change unknown trauma patient designated name from periodic elements to an electronic medical record generated name.  Clarified patient identifiers will be used once patient is able to be identified.  Removed the periodic elements reference table.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-141-03

Policy Name:  3364-131-25 Home wound V.A.C. (vacuum assisted closure) therapy
Description:  (Major revision to policy)   Updated policy purpose to clarify coordination of discharging patients with Durable Medical Equipment, specifically Wound Vacuum Assisted Closure Therapy.  Updated the procedure to clarify the admission assessment, documentation, benefits, financial information, and physician involvement.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-131-25

Policy Name:  3364-120-51 Informed consent for psychoactive medications
Description:  (Minor revision to policy)   Updated process to include oral or written format and include potential side effects to discussion with physician.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-120-51

Policy Name:  3364-120-64 Environmental safety checks
Description:  (Minor revision to policy)   Updated process with more detailed instructions.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-120-64

Policy Name:  3364-143-36 Transporting patients and staff to and from the main hospital and the child and adolescent psychiatric hospital
Description:  (Major revision to policy)   Updated process to included titles of licensed persons. Removed police option for transporting patient.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-143-36

Policy Name:  3364-31-35 Guardianship
Description:  (Major revision to policy)   Updated policy statement and purpose to clarify the process for determining if an appointment of a guardian is needed.  Updated the procedure to add outside resources.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-31-35

Policy Name:  3364-104-1005 Food on the clinical units
Description:  (Minor revision to policy)   Clarified the equipment cleaning process on clinical units.  Changed reference to Food and Nutrition Room to the Nourishment Room.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center – Food & Nutrition Services, Infection Prevention
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-1005

Policy Name:  3364-104-1001 General infection control
Description:  (Minor revision to policy)   Clarified the procedure for criteria included in personal hygiene.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center - Food & Nutrition Services
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-1001

Policy Name:  3364-104-806 Food and nutrition services - Calling off – staffing line
Description:  (Major revision to policy)   Clarified policy statement and purpose of the policy for calling off work and how it is appropriately monitored.  Updated the procedure to clarify call-off procedures, expectations, discipline, and appropriate approvals.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center – Food & Nutrition Services
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-806

Policy Name:  3364-104-804 Food and nutrition services - Dress code
Description:  (Minor revision to policy)   Updated the performance to clarify what is included in the uniform distribution.  Added reference to disposable apron’s, hair covering, facial hair, socks and shoe requirement, gloving, jewelry, etc.  Also, added guidelines for enforcing policy.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center – Food & Nutrition Services
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-804

Policy Name:  3364-104-716 Disaster feeding
Description:  (Minor revision to policy)   Updated the performance to clarify food procedures to include perishable, non-perishable, frozen items, food vendors, and water during a disaster situation.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center – Food & Nutrition Services
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-716

Policy Name:  3364-104-501 Performance improvement monitoring
Description:  (Minor revision to policy)   Updated the performance measures to include temperature of food, and courtesy of staff delivering tray. Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center – Food & Nutrition Services, Clinical Nutrition
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-501

Policy Name:  3364-104-319 Monitoring of patients with missed meals
Description:  (Minor revision to policy)   Updated procedure to clarify the time of day the patient missed meal report will be run.
Scope:  University of Toledo Medical Center – Food & Nutrition Services, Clinical Nutritio
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-319

Policy Name:  3364-104-305 Tray preparation and delivery
Description:  (Minor revision to policy)   Updated procedure to clarify how isolation patients who are not in their room at time of tray delivery will validate two patient identifiers.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center – Food & Nutrition Services
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-305

Policy Name:  3364-104-303 Family/guest tray service
Description:  (Minor revision to policy)   Updated Procedure to clarify how tray service for family members is managed related to food options and payment.  Other minor grammatical and formatting changes.
Scope:  University of Toledo Medical Center – Food & Nutrition Services
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-104-303

College of Medicine and Life Sciences – 1 policy

Policy Name:  3364-81-04-02-08 Research incentive program
Description:  (Minor revision to policy) Minor clarifying changes.
Scope:  University of Toledo College of Medicine and Life Sciences
Comment Period:  July 10, 2025 through August 11, 2025
Comment on this policy:  3364-81-04-02-08