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 policy number link after "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.
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 and Life Sciences - 3 Policies
Policy Name: 3364-81-18 COMLS Assigned education hours for FS curriculum
Description: (Minor revision) Changes to language defining what student assigned educational activities include
and do not include.
Scope: Associate Dean for Foundational Science Curriculum
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-81-18
Policy Name: 3364-81-11 COMLS Shadowing at UTMC and affiliated sites (non-medical students)
Description: (Minor revision) The policy changed how observers not enrolled in medical school observe at UToledo
Health instead of just UTMC. Limits the hours for observing for high school and undergraduate
students. Link to the Institutional Compliance Shadow Procedures given.
Scope: Senior Associate Dean for Undergraduate Medical Education/CMO UToledo Health
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-81-11
Policy Name: 3364-81-04-013-02 COMLS Academic Promotion Grading Criteria Remediation Dismissal
Description: (Minor revision) Minor revision: Changes affect those students matriculating after July 1, 2026. Clarifies
no grade curves and that pre-clerkship grades do not affect GPA, just performance
during clerkships will. Satisfaction with distinction is awarded to students meeting
90% for systems and received for meeting the minimum 90% in all Threads.
Scope: Senior Associate Dean for Undergraduate Medical Education, Assistant/Associate
Dean for Foundational Sciences. Associate Dean for Clinical Undergraduate Medical
Education and Senior/Associate Dean for Student Affairs
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-81-04-013-02
Research and Sponsored Programs - 1 Policy
Policy Name: 3364-70-03 Research Council
Description: (Major revision) The revised policy more clearly defines the purpose of the Research Council as the
faculty-led primary advisory body to the Vice President for Research (VPR). It streamlines
and redefines Research Council membership to align with recent college consolidations,
with one member representing each college, one appointed by the Graduate Council,
one by the Faculty Senate, and 5 additional faculty members appointed by the VPR to
maintain discipinary and subject-matter representation.
Scope: Defines the duties and responsibilities of the UToledo Research Council, all
campuses
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-70-03
UTMC - 7 Policies
Policy Name: 3364-109-GEN-705 Vascular Access Management
Description: (Minor revision) Clarified procedure and updated dressing change language. Other minor formatting
and grammatical changes. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-109-GEN-705
Policy Name: 3364-87-31 Determining when anesthesia services are necessary
Description: (Minor revision) Moved endoscopy procedures from procedures that typically do not require anesthesia
care to procedures that do typically require anesthesia care. Other minor formatting
and grammatical changes. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-87-31
Policy Name: 3364-100-70-01 Provider-Patient Relationships and Prescribing Standards
Description: (Minor revision) Policy name updated from Obtaining prescription medications without certified medical
indications to Provider-patient relationships and prescribing standards. Other minor
formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-100-70-01
Policy Name: 3364-100-85-03 Visitation of Patients
Description: (Minor revision) Patient visitation after regular hours changed from 8:30 pm to 6:30 am to 8:30 pm
to 8:30 am. Added reference to patient and visitor code of conduct.
Scope: University of Toledo Medical Center
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-100-85-03
Policy Name: 3364-100-70-18 Sepsis Alert Lactate, Standing Order
Description: (Minor revision) Clarified policy statement and policy purpose for patients admitted or arriving via
the emergency department, that have early signs of possible sepsis alert for any initial
needed intervention. Updated procedure related to ordering a reflex lactate. Other
minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-100-70-18
Policy Name: 3364-135-086 Quality assurance and safe operating procedures
Description: (Major revision) Updated procedure to clarify handwritten order requirements. related to ordering
a reflex lactate. Updated references to the Ohio Revised Code and updated contact
information for radiology personnel. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-135-086
Policy Name: 3364-135-102 Response to patient emergencies – hospital
Description: (Minor revision) Updated reference to policy number for patient emergencies. Added telephone number
for Rapid Response. Removed reference to Code 99. Other minor formatting and grammatical
changes.
Scope: University of Toledo Medical Center
Comment Period: July 27, 2026 - August 27, 2026
Comment on this policy: 3364-135-102