Office of Procedures, Records, and Forms Executive Policy Manual

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Executive Policy #5
Revision Approved November 5, 2018

Policy on Policies

Summary

This policy establishes the development, approval, and publication process for systemwide University policies and procedures, as defined below.

Policy Statement

By following a uniform process for policy approval and distribution, the University enhances operational efficiency, reduces institutional risk, and facilitates compliance with applicable laws, rules, and regulations.

University policies and procedures must be:

  • Written in understandable language and in a common format;
  • Approved by the appropriate University bodies and officials; and
  • Maintained on approved University policy publication websites.

Advisory guidelines that supplement University policies and procedures may be published and distributed on departmental websites.

Applicability

This policy applies to systemwide University policies and procedures related to administrative, business, and safety functions that affect many or most University units.

This policy does not apply to:

  • Policies and procedures that only affect operations at a single University campus or unit. Single campus or unit policies and procedures must be reviewed and approved by the responsible chancellor or unit head, after consultation and review by the Attorney General’s Office, the Office of Internal Audit, the Office of Risk Management, Human Resource Services, and/or other University offices, as applicable. Single campus or unit policies must not conflict with systemwide policies.
  • Academic policies. Academic policies include policies that directly affect the educational mission of the University, such as the Academic Regulations and the Graduate School Policies and Procedures. Academic policies are reviewed and approved by the Registrar, Graduate School, Office of the Provost, Faculty Senate, and/or other University offices, as applicable.
  • Personnel manuals and handbooks. Although the Faculty Manual and the Administrative Professional Handbook incorporate policies/procedures within the scope of this policy, changes to such manuals themselves are outside the scope of this policy. New policies/ procedures or changes that significantly impact faculty must be vetted with the appropriate Faculty Senate committee prior to implementation.

Definitions and Responsibility

Advisory Guideline

 An advisory guideline provides a recommended, but not required, method for implementing an administrative process.

Nonsubstantive Change

A nonsubstantive change is defined as a revision in grammar, formatting, URL update, titles, or organizational structure, and other revisions of similarly low impact.

Publishing Department

The publishing department is the department that publishes the policy/procedure in an official University publication. (See Implementation, Distribution, and Publication.) The department is also responsible for retaining superseded policies and procedures in accordance with the University’s records retention schedule. (See Retention of Superseded Policies and Procedures.)

The Office of Procedures, Records, and Forms publishes and ensures that proposed policies/ procedures follow the correct format if the documents are to be published in the Executive Policy Manual (EPM), Business Policies and Procedures Manual (BPPM), or Safety Policies and Procedures Manual (SPPM).

Responsible  Department

The responsible department is the department that implements and administers the policy/procedure. The department is responsible for preparing the document in accordance with the requirements of this policy. The department is also responsible for periodic review of existing policies and procedures. (See Review of Existing Policies and Procedures.)

Responsible Official

Responsible officials include the President, Provost, any vice president, or any employee or employees designated by these individuals to provide approval of a University policy or procedure on behalf of a responsible department.

University Policy

A policy is a plan or general course of action, having broad application throughout the University, intended to influence and determine decisions, actions, and other matters. A policy helps to ensure compliance with applicable laws and regulation, promotes operational efficiencies, promotes one or more of the University’s missions, and/or reduces risk to the institution.

University Procedure 

A procedure is an established method of implementing a University policy.

Procedure 

  1. Analysis and Proposal: The responsible department analyzes and conceptualizes the substance of a policy/procedure or amendments to an existing policy/procedure.
  2. Approval to Proceed: When seeking to implement a new policy/procedure or to repeal an existing policy/procedure, the responsible department must route a summary of the proposal with an analysis to the responsible official. The responsible official determines whether or not the proposed action proceeds.
  3. Draft Preparation: The responsible department prepares or works with the publishing department to prepare a draft of the proposed new policy/procedure or amendment.
  4. Preliminary Review/Approval
    1. The responsible department or the publishing department routes the first draft to individuals or offices immediately involved with the proposed policy.
    2. After considering input from the individuals or offices, the responsible department or the publishing department routes the proposed policy with a supporting policy analysis to the responsible official. The responsible official may take one of the following actions regarding the proposed policy:
      • Route the proposal back to the responsible department and/or the publishing department noting that the policy is not to be considered further.
      • Route the proposal back to the department or the publishing department for further analysis, for consideration of other options, or redrafting.
      • Route the proposal to University organizations, offices, and constituencies for review and preliminary approval. NOTE: If a proposal is substantially revised, it may be routed back to the reviewing organizations, offices, and constituencies for another review round.

        The Attorney General’s Office; Human Resource Services; Council of Deans, Office of Internal Audit; Office of Risk Management; Office of Research are a few of the offices and groups that may need to be included in this review, depending upon subject matter and scope of the proposal. NOTE: Although this policy does not apply to academic policies or personnel manuals, many policies within the scope of this policy impact those areas. Substantive policy modifications or new policies that significantly impact the academic enterprise or faculty employment must be routed to the Provost’s Office and the faculty senate executive committee.

    3. When policy/procedure changes are required by law or legislation, University administration recommends expediting the revision process as quickly as possible.
  5. Final Approval: The following instructions apply to final review:
    1. Procedures: A director may approve procedural statements or changes that do not include policy changes. However, procedures with broad University impact and scope should be approved by the responsible official.
    2. Policies: The Office of the President determines whether the responsible official gives final approval, or whether final approval by President’s Cabinet is needed. In some cases, Board of Regents’ approval may be required.
    3. Routing: Once the director or responsible official, as applicable, determines that the policy/procedure is ready for final approval, they take one of the following actions:
      • For EPM, BPPM, or SPPM policies/procedures, the director or responsible official, as applicable, routes the draft to the Office of Procedures, Records, and Forms. The Office of Procedures, Records, and Forms routes it to the Office of the President for determination of the appropriate authority for final approval of the policy/procedure.
      • For policies/procedures intended for publication in other approved University publications (see Implementation, Distribution, and Publication), the director or responsible official, as applicable, routes the draft to the applicable publishing department. The publishing department routes it to the Office of the President for determination of the appropriate authority for final approval.
    4. Considerations: Final reviewers are to consider a proposal’s consistency with University priorities and directions, impact upon operations, and ease of administration.
  6. Implementation, Distribution, and Publication: Final approval must be communicated in writing to the responsible department and/or the publishing department.

    The responsible department, in consultation with the publishing department, determines how best to notify the campus community of the new policy/procedure or policy/procedure change. The new or revised policy/procedure is then published as follows:

    • The Office of Procedures, Records and Forms publishes the policy/procedure on its official policy website for the Executive Policy Manual (EPM), the Business Policies and Procedures Manual (BPPM), and the Safety Policies and Procedures Manual (SPPM); or
    • The applicable publishing department publishes the policy/procedure in another approved publication. Approved University publications include the Institutional Animal Care and Use Committee Manual, the Institutional Biosafety Committee Manual, the Institutional Review Board Manual, the Laboratory Safety Manual, the Office of Research Support and Operations (ORSO) Policies and Guidelines, and the Radiation Protection Program Manual.
    • Official and approved systemwide University policies and procedures must not be republished on departmental websites or in personnel manuals. Instead, departmental websites and personnel manuals must link to official policy/procedure websites when references are required in order to ensure references are up to date.

Recommended Format

The recommended standard format for policy and procedure statements includes the following elements: effective date, revision date, policy or overview, applicability, definitions, and procedures.

The recommended standard format for advisory guideline statements includes the following elements: effective date, revision date, reference to the related approved University policy, applicability, guidelines.

Revisions, Periodic Review, and Retention Requirements

Revision

Responsible departments follow the procedures indicated above when revising existing policies and procedures.

Review of Existing Policies and Procedures

The responsible department must ensure that the policy/procedure document reflects current practices and is consistent with current legal requirements. The responsible department must review the document at least once every three years and update it as necessary in conformance with the procedures provided above. Any time operational changes occur that impact the content of the policy/procedure document, the responsible department must conduct a formal review and process any necessary revisions in conformance with the procedures provided above. Documentation of any EPM, BPPM, or SPPM policy/procedure review is to be forwarded to the Office of Procedures, Records, and Forms for retention.

Retention of Superseded Policies and Procedures

Publishing departments are responsible for retaining policies and procedures for at least six years after they are superseded. See BPPM 90.01.