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 – 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
General and Undergraduate Academic – 1 policy
Policy Name: 3364-71-33 Intellectual diversity and controversial beliefs
Description: (New policy) This policy has been proposed to comply with Ohio Revised Code 3345.0217.
Scope: All University of Toledo Campuses
Comment Period: June 25, 2025 through July 25, 2025
Comment on this policy: 3364-71-33
The following five policies have been rescinded, effective immediately, and are posted for the 30-day comment period:
Equity & Diversity – 3 policies
Policy Name: 3364-12-01 Supplier diversity
Description: (Policy has been rescinded) Policy has been rescinded to comply with changes in the law.
Scope: All University of Toledo Campuses
Comment Period: June 25, 2025 through July 25, 2025
Comment on this policy: 3364-12-01
Policy Name: 3364-12-02 Diversity training
Description: (Policy has been rescinded) Policy has been rescinded to comply with changes in the law.
Scope: All University of Toledo Campuses
Comment Period: June 25, 2025 through July 25, 2025
Comment on this policy: 3364-12-02
Policy Name: 3364-12-03 Inclusive gender practices
Description: (Policy has been rescinded) Policy has been rescinded to comply with changes in the law.
Scope: All University of Toledo Campuses
Comment Period: June 25, 2025 through July 25, 2025
Comment on this policy: 3364-12-03
College of Medicine & Life Sciences – 1 policy
Policy Name: 3364-81-04-022-01 Process and criteria for achievement of diversity and excellence
in the medical school class
Description: (Policy has been rescinded) Policy has been rescinded to comply with changes in the law.
Scope: College of Medicine & Life Sciences MD Program
Comment Period: June 25, 2025 through July 25, 2025
Comment on this policy: 3364-81-04-022-01
Policy Name: 3364-81-11-001-00 Clinical and non-clinical faculty recruitment
Description: (Policy has been rescinded) Policy has been rescinded to comply with changes in the law.
Scope: College of Medicine & Life Sciences Faculty
Comment Period: June 25, 2025 through July 25, 2025
Comment on this policy: 3364-81-11-001-00