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:
Academic Affairs - 2 policies
Policy Name: 3364-71-34 Institutional data governance committee
Description: (New policy) Establishes the authority of a formal Data Governance Committee to 1) set data management
principles and standards for the caretaking and use of institutional data, and 2)
assign data stewardship responsibilities for assuring the accuracy, consistency, and
completeness of data.
Data governance procedure
Scope: All university organizational units working with institutional data
Comment Period: January 30, 2026 - March 02, 2026
Comment on this policy: 3364-71-34
Policy Name: 3364-71-35 Academic program review
Description: (New policy) The policy defines the goals of the academic program review process, an ongoing formal
evaluation of current academic programs.
Academic program review procedure
Scope: All academic programs
Comment Period: January 30, 2026 - March 02, 2026
Comment on this policy: 3364-71-35
College of Medicine and Life Sciences - 2 policies
Policy Name: 3364-81-04-013-05 COMLS Graduation Requirements for the MD Program
Description: (Minor changes) Revisions in this policy reference the number of weeks of instruction in the 4th year with the addition of a new 2-week Emergency Medicine Core Rotation and new Final
Foundations course.
Scope: College of Medicine and Life Sciences
Comment Period: Februrary 17, 2026 - March 17, 2026
Comment on this policy: 3364-81-04-013-05
Policy Name: 3364-81-04-018-00 The Learning Environment and Faculty Professionalism
Description: (Minor revision of existing policy)
Scope: College of Medicine and Life Sciences
Comment Period: January 30, 2025 - March 02, 2026
Comment on this policy: 3364-81-04-018-00
Compliance - 1 Policy
Policy Name: 3364-15-02 Detecting and preventing fraud waste and abuse
Description: (Major revision of an existing policy) Updates include the policy statement, purpose, scope, definitions, whistleblower protections,
consequences, and reporting requirements.
Scope: All University campuses, including vendors and contractors
Comment Period: January 30, 2025 - March 02, 2026
Comment on this policy: 3364-15-02
Human Resources - 2 Policies
Policy Name: 3364-50-02 Nondiscrimination
Description: (Minor Revision of existing policy) Added wording regarding co-investigating with Title IX when matters are covered under
both policies. Changed calendar days to business days. Adjusted the specific number
of days to a more general wording for investigative procedures. Minor formatting and
grammatical changes.
Scope: All University of Toledo Campuses
Comment Period: Februrary 17, 2026 - March 17, 2026
Comment on this policy: 3364-50-02
Policy Name: 3364-25-44 Independent Contractor Status
Description: (Minor Revision of existing policy) We have added rules to clarify who may work as an independent contractor to comply
with OPERS requirements.
Scope: All University of Toledo Campuses
Comment Period: Februrary 17, 2026 - March 17, 2026
Comment on this policy: 3364-25-44
UTMC - 11 policies
Policy Name: 3364-100-85-04 Lead Garment Purchase, Inspection, Identification and Care
Description: (New Policy) Created new policy to include University of Toledo Medical Center – All Radiology
Locations. The new policy clarifies all processes required for lead garment purchase,
inspection, identification, and care for all areas. Rescinded Radiology Policy 3364-135-152.
Scope: University of Toledo Medical Center
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-100-85-04
Policy Name: 3364-118-20 Management of HBV and other blood borne pathogens in the dialysis unit-infection
control
Description: (Major revision of existing policy) Revised and/or added details to the specific steps to be taken in the hemodialysis
unit to prevent the spread of Hepatitis B and other bloodborne pathogens, as well
as management of exposure to HBsAG (+) dialysis patients.
Scope: University of Toledo Medical Center
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-118-20
Policy Name: 3364-120-48 Description of Therapeutic Milieu and Treatment Interventions
Description: (Consolidation of existing policies and guidelines) No major changes to content, eliminating duplicate information and combining into
one policy that applies to both the child/adolescent psychiatric hospital and senior
behavioral health. This policy and guideline: Program elements were combined; the
guideline: Program elements will be rescinded.
Scope: University of Toledo Medical Center
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-120-48
Policy Name: 3364-120-39 Duty to Warn/Duty to Protect
Description: (Consolidation of existing policies and guidelines) No major changes to content, eliminating duplicate information and combining into
one policy that applies to both the child/adolescent psychiatric hospital and senior
behavioral health. This policy and policy 3364-122-42 Duty to Protect were combined;
the policy 3364-122-42 Duty to Protect will be rescinded.
Scope: University of Toledo Medical Center
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-120-39
Policy Name: 3364-122-13 Elopement Precautions and Processes
Description: (Consolidation of existing policies and guidelines) No major changes to content, eliminating duplicate information and combining into
one policy that applies to both the child/adolescent psychiatric hospital and senior
behavioral health. This policy and policy 3364-120-74 Absent without Leave and guideline:
Runaway precautions were combined; the policy 3364-120-74 Absent without Leave and
guideline: Runaway precautions will be rescinded.
Scope: University of Toledo Medical Center
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-122-13
Policy Name: 3364-120-66 Suicide Assessment and Prevention
Description: (Consolidation of existing policies and guidelines) No changes to content, eliminating duplicate information and combining into one policy
that applies to both the child/adolescent psychiatric hospital and senior behavioral
health. This policy and policy 3364-122-12 Suicide Assessment and Prevention were
combined; the policy 3364-122-12 Suicide Assessment and Prevention will be rescinded.
Scope: University of Toledo Medical Center
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-120-66
Policy Name: 3364-122-22 Individualized Multidisciplinary Treatment Plan and Treatment Team Protocol
Description: (Consolidation of existing policies and guidelines) No major changes to content, eliminating duplicate information and combining into
one policy that applies to both the child/adolescent psychiatric hospital and senior
behavioral health. This policy and policy 3364-120-43 Treatment Team Protocol and
guideline: Treatment planning process were combined; the policy 3364-120-43 Treatment
Team Protocol and guideline: Treatment planning process will be rescinded.
Scope: University of Toledo Medical Center
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-122-22
Policy Name: 3364-120-06 Admission Criteria and Screening - Inpatient Behavioral Health
Description: (Consolidation of existing policies and guidelines) No major changes to content, eliminating duplicate information and combining into
one policy that applies to both the child/adolescent psychiatric hospital and senior
behavioral health. This policy and policy 3364-122-43 Admission Criteria for Inpatient
Psychiatry and guideline: Inquiry and pre-admission screening were combined; the policy
3364-122-43 Admission Criteria for Inpatient Psychiatry and guideline: Inquiry and
pre-admission screening will be rescinded.
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-120-60
Policy Name: 3364-120-13 Nursing Admission Process and Procedures
Description: (Consolidation of existing policies and guidelines) No major changes to content, eliminating duplicate information and combining into
one policy that applies to both the child/adolescent psychiatric hospital and senior
behavioral health. This policy and policies 3364-120-14 Procedure for Voluntary and
Involuntary Admissions, 3364-120-31 Direct Admissions, and 3364-122-41 Admission Process
were combined; the policies 3364-120-14 Procedure for Voluntary and Involuntary Admissions,
3364-120-31 Direct Admissions, and 3364-122-41 Admission Processwill be rescinded.
Scope: University of Toledo Medical Center
Comment Period: February 17, 2026 - March 17, 2026
Comment on this policy: 3364-120-13
Policy Name: 3364-100-45-04 Care of Inpatient on Hospice Agency Services
Description: (Minor revision of existing policy) Updated procedure to remove patient personal attire, personal item(s), administrative
language, and visitation requirements. Other minor formatting and grammatical changes.
Scope: University of Toledo Medical Center
Comment Period: January 30, 2026 - March 02, 2026
Comment on this policy: 3364-100-45-04
Policy Name: 3364-118-20 Management of HBV and Other Blood Borne Pathogens in the Dialysis Unit-Infection
Control
Description: (Major revision of existing policy) Clarified and provided greater detail overall. Added section (C)(7) - Management
of exposure to HBsAG (+) dialysis patients, as aweel as current reference materials.
Scope: University of Toledo Medical Center
Comment Period: January 30, 2026 - March 02, 2026
Comment on this policy: 3364-118-20