University Policy

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.

College of Medicine and Life Sciences (6 policies)
General Administration ( 1 policy)
Research ( 1 policy)
UTMC ( 8 policies)


College of Medicine and Life Sciences (6 policies)

Policy Name:   Recently Signed 3364-81-04-007-00  Satisfactory Academic Progress in the Required Clinical Clerkships
Description:  (Major revision of existing policy)   The purpose of this policy is to ensure satisfactory academic progress through the required clinical clerkship curriculum.
Scope:  M.D. program in College of Medicine and Life Sciences
Comment Period:   April 2, 2015 – May 4, 2015
Comment on this policy  3364-81-04-007-00 

Policy Name:   Recently Signed 3364-81-04-013-08 Assigned education hours for preclinical medical education
Description:  (Minor/technical revision of existing policy)   The Office of Medical Education in the College of Medicine will ensure that there is an appropriate balance of assigned educational activities during the preclinical curriculum and time that is deemed necessary for student self-directed learning and study.
Scope:  College of Medicine and Life Sciences MD Program
Comment Period:   April 8, 2015 – May 8, 2015
Comment on this policy  3364-81-04-013-08

Policy Name:   Recently Signed 3364-81-04-011-00  Curriculum modification; standards that require curriculum committee involvement
Description:  (Affirmation of existing policy)   The College of Medicine Curriculum Committees oversee the educational program leading to the doctor of medicine degree.  Any changes that impact the College of Medicine curriculum must be reviewed and approved by the Executive Curriculum Committee and the Dean, College of Medicine, prior to implementation.
Scope:  All University of Toledo Campuses
Comment Period:   April 8, 2015 – May 8, 2015
Comment on this policy  3364-81-04-011-00

Policy Name:   Recently Signed 3364-81-04-013-01  Medical student evaluation in the four-year curriculum:  preclinical
Description:  (Minor/technical revision of existing policy)   Students will be given the general objectives, methods of evaluation, and criteria for successful completion at the beginning of each curriculum component.  Grading shall be based on the extent to which a student accomplishes specified educational goals and/or achieves expected levels of clinical skill.
Scope:  All University of Toledo Campuses
Comment Period:   April 8, 2015 – May 8, 2015
Comment on this policy  3364-81-04-013-01

Policy Name:   Recently Signed 3364-81-04-016-04  Student training for occupational exposure
Description:  (Reaffirmation of existing policy)   All students must be given adequate opportunity to be educated concerning the risks of occupational exposures to infectious and environmental hazards.  The purpose of the policy is to minimize risk to students from infectious and environmental hazards in their learning environment.
Scope:  All University of Toledo Campuses
Comment Period:   April 8, 2015 – May 8, 2015
Comment on this policy  3364-81-04-016-04

Policy Name:   Recently Signed 3364-81-04-014-05 Excused absences from required academic activities in the preclinical years (MD Program)
Description:  (Minor/technical revision of existing policy)   Attendance is mandatory for all examinations and summative and formative assessments, as well as for specified classes and academic activities in the preclinical years.  Thus, policies and procedures for the timely notification of all appropriate parties in the event of an absence, as well as for requesting a formal excuse for the absence, have been developed, implemented, and enforced.
Scope:  Medical students in the preclinical years, UT College of Medicine and Life Sciences
Comment Period:   April 8, 2015 – May 8, 2015
Comment on this policy  3364-81-04-014-05


General Administration (1 policy)

Policy Name:   Draft 3364-5-14  Expression on campus
Description:  (New policy proposal)   The purpose of the policy is to promote the free exchange of ideas and the safe and efficient operation of the university by: fostering free speech, assembly, and other expressive activities on publicly accessible outdoor areas of any university campus by any persons, whether or not they are affiliated with the university, and regardless of the viewpoint being expressed; maintaining an appropriate educational and work environment for all persons present on university property, including but not limited to students, faculty, employees, customers, and visitors; maintaining the personal security of all persons present on university property and protecting the property of the university and of persons present on university property.
Scope:  All campuses (as set forth in section (B))
Comment Period:   April 15, 2015 – May 15, 2015
Comment on this policy:  3364-5-14


Research (1 policy)

Policy Name:   Draft 3364-70-10  Laboratory animal welfare, care and use
Description:  (Minor/technical revision of existing policy)    The University of Toledo (UT) acknowledges and accepts responsibility for the care and use of animals involved in all research and educational activities conducted under the auspices of this institution.  UT has established and will maintain a program for activities involving animals in accordance with the Guide for the Care and Use of Laboratory Animals (the Guide) (National Academy Press, 2011 or as revised.  UT also conforms to other applicable federal, state, and local statutes and regulations relating to animal care and use.  Revisions are tracked on the posted draft policy.
Scope:  all University of Toledo campuses
Comment Period:   April 8, 2015 – May 8, 2015
Comment on this policy  3364-70-10


UTMC ( 8 policies)

Policy Name:   Draft 3364-100-90-19 Social Media
Description:  (New policy)   Social media is a powerful tool that can lead to collaboration and improved patient care.  However, it also has the potential to divulge protected patient information and lower society’s trust and opinion of the institution and profession of medicine.  The purpose of this policy is to mitigate the risk and to establish guidelines for hospital staff on the use of social media.
Scope:  UTMC
Comment Period:   April 2, 2015 – May 4, 2015
Comment on this policy  3364-100-90-19

Policy Name:   Draft 3364-100-01-07  Elective Admissions
Description:  (Reaffirmation of existing policy)   The purpose of the policy is to assure all elective admissions will have some means of payment, or have pre-arranged assistance, for hospital charges.
Scope:  UTMC
Comment Period:   April 2, 2015 – May 4, 2015
Comment on this policy  3364-100-01-07

Policy Name:   Draft 3364-100-60-02 Patient Rights and Responsibilities
Description:  (Minor/technical revision of existing policy)   The purpose of the policy is to specify patient’s rights and responsibilities in order to build a relationship needed between the UTMC physicians, clinical personnel, staff and the patient to promote quality care.
Scope:  UTMC
Comment Period:   April 2, 2015 – May 4, 2015
Comment on this policy  3364-100-60-02

Policy Name:   Draft 3364-100-45-20  Market Withdrawal/Recalls
Description:  (Reaffirmation of existing policy)   Market withdrawal and/or recalls (MW/R) are initiated by the American Red Cross for a variety of reasons.  UTMC policy is to determine if patient notification is necessary in cases of Market Withdrawal and or recall of products initiated by the American Red Cross.
Comment Period:   April 2, 2015 – May 4, 2015
Comment on this policy  3364-100-45-20

Policy Name:   Draft 3364-100-53-23  Fecal Occult Blood Testing
Description:  (Minor/technical revision of existing policy)   Fecal Occult Blood testing must comply with standards established by The Joint Commission and CLIA.  To ensure compliance with The Joint Commission and CLIA standards, there must be documentation of testing and Quality Controls, with attributable responsibility for testing.
Scope:  UTMC and its Medical Staff
Comment Period:   April 2, 2015 – May 4, 2015
Comment on this policy  3364-100-53-23

Policy Name:   Draft 3364-100-50-20  Transplantation Patient Selection Committee
Description:  (Minor/technical revision of existing policy)   UTMC will have multi-disciplinary committees for the selection of patients for organ transplantation which will comply with national, state and other regulatory standards.  The purpose of the policy is to select patients for organ transplantation at UTMC.
Scope:  UTMC
Comment Period:   April 2, 2015 – May 4, 2015
Comment on this policy  3364-100-50-20

Policy Name:   Draft 3364-100-01-16  Patient Identification
Description:  (Major revision of existing policy)   All patients (inpatients and outpatients) of The University of Toledo Medical Center are properly identified prior to the provision of any care, treatment or services provided.  A system for positive identification for all hospital patients fulfills four (4) basic functions:  provides positive identification of patients from the time of admittance for treatment; provides a positive method of linking patients to their medical records and treatment; minimizes the possibility that identifying data can be lost or transferred from one patient to another; and improves the accuracy of patient identification and patient safety.
Scope:  UTMC
Comment Period:   April 6, 2015 – May 6, 2015
Comment on this policy  3364-100-01-16

Policy Name:   Draft 3364-100-70-10  Medication Management
Description:  (Minor/technical revision of existing policy)   Medication orders must be clear, complete, and non-ambiguous.  The purpose of the policy is to support safe medication prescription and ordering procedures.
Scope:  The University of Toledo Medical Center and its Medical Staff
Comment Period:   April 15, 2015 – May 15, 2015
Comment on this policy:  3364-100-70-10


Recommendations to Rescind a Policy 

Policies recommended for rescission are posted here for comment by The University of Toledo community for thirty days. Please direct any comments or questions regarding the policies recommended for rescission to policies@utoledo.edu

Last Updated: 4/15/15