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: 3364-81-04-013-06 Grading Policy for Required Clinical Clerkships
Description: (Minor/technical revision of existing policy)
Scope: College of Medicine M.D. Program
Comment Period: September 11, 2025 through October 11, 2025
Comment on this policy: 3364-81-04-013-06
Title IX - 1 policy
Policy Name: 3364-50-01 Title IX
Description: (Minor/technical revision of existing policy)
Scope: All University of Toledo campuses
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-50-01
UTMC - 21 policies
Policy Name: 3364-141-01 Trauma Registry
Description: (Minor revision of existing policy) Updated Procedure for case finding/data sources related to reporting and concurrent
data collection. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-141-01
Policy Name: 3364-100-55-09 Patient with Massive GI Bleed Presenting to the ED
Description: (Minor Revision) Removed reference to surgery residents/training and added acute care surgeon on-call
to assume lead. Updated resuscitation procedure. Other minor grammatical and formatting
changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-55-09
Policy Name: 3364-104-101 Ethical Issues
Description: (Minor revision of existing policy) Removed reference to policy number for DNR policy.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-104-101
Policy Name: 3364-110-08-01 Review of Nursing Staffing Data
Description: (Minor Revision) Summary of changes: removed specific titles and software name.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-110-08-01
Policy Name: 3364-134-42 Physics Chart Check, Final Physics
Description: (Minor revision of existing policy) Clarified procedure and removed obsolete language/process. Minor formatting and
grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-134-42
Policy Name: 3364-146-03 Financial Clearance: Elective Services
Description: (Minor revision of existing policy) Split out Hospital Inpatient criteria from Outpatient and Ambulatory. Added Inpatient
Hospital criteria for admissions, third party coverage, private pay, etc., for inpatient
financial clearance. Minor formatting and grammatical changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-146-03
Policy Name: 3364-100-53-11 Sedation/Analgesia by Non-Anesthesiologists
Description: (Minor Revision) Updated policy statement to include sedation documentation requirements and continuity
of care. Updated procedure to include culturally and linguistically appropriate communications
and interpreter services. Added sedation annual training and competency validation
requirements. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-53-11
Policy Name: 3364-100-55-08 Clinic Cancellations
Description: (Minor Revision) Added Utoledo Health to the policy statement. Added
division chief to the policy purpose and procedure. Updated reporting, timeframes
for submitting requests, and exceptions to the six-week rule. Other minor grammatical
and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-55-08
Policy Name: 3364-100-45-24 Hospital Clinical Alarms
Description: (Minor Revision) Removed reference to the Joint Commission standard number and referenced the name
of the standards/chapter in the policy statement. Other minor grammatical and formatting
changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-45-24
Policy Name: 3364-100-45-09 Blood Transfusion Reaction Protocol
Description: (Minor Revision) Updated procedure, removed reference to nursing guidelines and added that the nurse
will reference guidance documents in Mosby’s for further direction. Other minor grammatical
and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-45-09
Policy Name: 3364-100-35-01 Designation of Authority During Absence of CEO
Description: (Minor Revision) Updated policy statement and procedure to clarify chain of command in the absence
of the Chief Executive Officer. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-35-01
Policy Name: 3364-100-05-01 Scheduled and Unscheduled Computer Downtime
Description: (Minor Revision) For scheduled downtime, added that the decision to call a code copper will be in conjunction
with IT. For unscheduled downtime, removed process for when an estimated length of
downtime is determined, it will be made available via the IT Help Desk automated attendant
recording. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-05-01
Policy Name: 3364-100-01-22 Protecting the Privacy of Patients During Medical Encounters
Description: (Minor Revision) Clarified policy statement, purpose, and scope of policy. Updated definitions to
include guardian. Procedure clarifications to include informed consent, required
documentation, references to minors, responsibility for establishing guidelines and
to ensure patients are informed of their rights to request a chaperone. Other minor
grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-01-22
Policy Name: 3364-100-01-18 Notification of Hospital Discharge Rights
Description: (Minor Revision) Added definitions for Important Message from Medicare and Patient Representative.
Updated procedure, follow-up notice, beneficiary requesting QIO review, and QIO notice
to hospital of determination. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-01-18
Policy Name: 3364-100-01-13 Confidential Patients
Description: (Minor Revision) Clarified policy statement, policy purpose and procedure to ensure no identifying
information is disclosed to unauthorized individuals. Safeguards privacy and safety
of patients who are at risk or who request confidentiality during their care episode.
Policy ensures consistent handling of sensitive cases across all departments and aligns
with institutional privacy and security standards. The procedure updates include
Registration Protocol, Information Handling, Staff Responsibilities, and Audit and
Compliance. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-01-13
Policy Name: 3364-100-01-02 Leave of Absence for Patients
Description: (Minor Revision) Under procedure, clarified that the leave of absence form will be scanned and documented
in the electronic medical record. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-01-02
Policy Name: 3364-100-53-02 Supplier Visitation to Operating Rooms and other Procedural Areas
Description: (Minor Revision) Updated title of policy, policy statement, purpose, and procedure to include all procedural
areas. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-53-02
Policy Name: 3364-100-50-34 Critical Incident Debriefing
Description: (Minor Revision) Under procedure, updated contact information for additional resources. Other minor
grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-50-34
Policy Name: 3364-100-50-27 Scrubs – Authorized Use and Security
Description: (Minor Revision) Clarified departments and personnel under policy statement. Updated procedure to
clarify that scrubs will be delivered and kept in scrub machines, wearing and transporting
scrubs offsite is prohibited, distribution of scrubs as appropriate for the job/department
by department leaders, and who to call with any questions. Other minor grammatical
and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-50-27
Policy Name: 3364-100-50-13 Plan for Prisoner-Patients Who Require Security Services Provided by
a Law Enforcement Agency
Description: (Minor Revision) Under procedure, added clarification that the Admitting Department (e.g., Emergency
Department) will notify Health Science Campus (HSC) security when a prisoner patient
is admitted. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-100-50-13
Policy Name: 3364-110-05-11 Peripherally Inserted Central Catheters
Description: (Minor Revision) Clarified policy statement and purpose of the policy. Updated procedure to include
clarification of blood cultures, timing of results to meet criteria to insert PICC
lines, and infection control involvement. Added demonstrated competency requirement
for PICC line removal to policy. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: September 10, 2025 through October 10, 2025
Comment on this policy: 3364-110-05-11