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:
University of Toledo Medical Center – 8 policies
Policy Name: 3364-104-320 Patient menus
Description: (Minor revision of existing policy) Added acronym language for FANS (Food and Nutrition Services), NCM (Nutrition Care
Manual), and Pharmacy and Therapeutics Committee (P&T). Removed reference to the
year of the NCM worksheet approved by P&T Committee. Other minor grammatical and
formatting changes.
Scope: University of Toledo Medical Center, Food & Nutrition Services, Clinical Nutrition
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-104-320
Policy Name: 3364-104-333 Diet manual
Description: (Minor revision of existing policy) Updated the year to reflect the 2025 edition of the Nutrition Care Manual, approved
by the hospital. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-104-333
Policy Name: 3364-133-70 Standard medication administration times
Description: (Minor revision of existing policy) Updated Standard Medication Administration Times graph. Other minor grammatical
and formatting changes.
Scope: University of Toledo Medical Center
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-133-70
Policy Name: 3364-133-98 Therapeutic drug monitoring
Description: (Minor revision of existing policy) Updated Pharmacist Order of Lab and Test References Graph. Other minor grammatical
and formatting changes.
Scope: University of Toledo Medical Center
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-133-98
Policy Name: 3364-133-126 Medical marijuana
Description: (Minor revision of existing policy) Policy statement clarification to add recreational marijuana into description of
cannabis that will not be permitted in the University of Toledo Medical Center. Other
minor grammatical and formatting changes.
Scope: University of Toledo Medical Center
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-133-126
Policy Name: 3364-133-135 IVP medications
Description: (Minor revision of existing policy) Updated color of procedural graph to color of red for IV Push, should only be giving
in the event of an emergency category. Other minor grammatical and formatting changes.
Scope: University of Toledo Medical Center
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-133-135
Policy Name: 3364-133-143 Therapy management by the pharmacist
Description: (Minor revision of existing policy) Updated Drug and Intervention Order graph to reflect changes for respiratory nebulization
therapy management, stress ulcer prophylaxis, disease state adjustments, dose rounding
and dose wight adjustment, and consult management. Other minor grammatical and formatting
changes.
Scope: University of Toledo Medical Center
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-133-143
Policy Name: 3364-160-CR-106 Progress note
Description: (Minor revision of existing policy) Clarified progress note requirements for each service type, expanded required documentation
details, allowed for crisis services not on the treatment plan, and added guidance
for noting patient risk of harm.
Scope: OP Clinic - Psychiatry
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-160-CR-106
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) Minor clarifying revisions.
Scope: Faculty in the College of Medicine & Life Sciences
Comment Period: August 5, 2025 through September 4, 2025
Comment on this policy: 3364-81-04-018-00
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