This Procedure implements the Policy on Policies and Procedures (UP01-001). It sets forth the standard steps for the initiation, review, approval, and publication of new University Policies and University Procedures; the ongoing review, modification, and elimination of policies and procedures; the Standard Policy Template for drafting and publishing policies and procedures; and the University’s central policy and procedure library—the University Policy Webpage.


A. Presidential Authority. The President, as chief executive officer of the University, is empowered to adopt University Policies and Procedures. Such Policies and Procedures are to be consistent with policies adopted by the Board of Directors the University and are to be within the limits established by the Board. The President accepts, rejects, or modifies Policies in consultation with, and upon the recommendation of, the Cabinet and others, as described below. In most University Policies, the President delegates to a Responsible Executive the authority for adopting supportive University Procedures. Policies and procedures established by Responsible Executives to guide the affairs of their particular areas of responsibility are to conform to the policies of the President and of the Board of Directors.

B. Policy Idea. A policy idea may be submitted for approval by:
1. Using the Policy Development Form to describe the policy idea, identify Constituents and submit the completed Policy Development form to the Responsible Executive.
2. The Responsible Executive advances the process by submitting the Policy Development Form to the Cabinet for review and approval of the policy idea.

C. Draft Policy. Upon approval of the policy idea by the Cabinet, the Responsible Office, under the direction of the Responsible Executive:
1. Formulates the entire policy document using the Standard Policy Template.
2. Circulates the draft policy for review and comment to appropriate Constituents. Comments and any required changes are to be incorporated by the Responsible Executive in a revised draft, and the process is repeated until a final draft is prepared.
3. Presents the final draft and seeks its review and approval by the Cabinet.
4. Prepares draft of the electronic memo to accompany the proposed new or revised policy release following final approval. (See Section III. A. 2, below)

D. Draft Procedure. For a procedure, the Responsible Executive may adopt the new procedure after presentment to the Cabinet for comment during a Comment Period and upon review and approval as to legal form by the General Counsel. The Responsible Executive prepares a draft of the electronic memo to accompany the proposed new or revised procedure release following legal review and approval. (See Section III. A. 2, below)

E. Additional Steps, for Policies Only:
1. Cabinet Review & Approval. Before the Cabinet can recommend formal adoption to the President, the policy, in final draft form, must be read and approved at two Cabinet meetings. The first reading and approval will take place prior to the Comment Period.
2. Comment Period. The policy, in its final draft form, will be posted on the University’s website and distributed via electronic communication, i.e., FSA (current Faculty, Staff & Administrators) and any other appropriate listserv, to commence the policy Comment Period.
3. Post-Comment Period Review & Approval. The second reading and approval by the Cabinet will take place following the Comment Period, with any incorporation of any appropriate revisions. The Cabinet may then recommend formal adoption by the President.

F. Legal Review & Approval
1. Policies. Following the second reading and approval by the Cabinet the policy will be forwarded to the General Counsel in its final form for a review of the details of the formulation process and for approval as to legal form and for compliance with legal and regulatory requirements. If no further revisions are required, the General Counsel will forward the policy, in print format, to the President for approval and signature.
2. Procedures. As part of the notice to the Cabinet and the Comment Period, the proposed procedure will be delivered to the General Counsel in its final form for a review of the details of the formulation process, for approval as to legal form, and for compliance with legal and regulatory requirements.

G. Final Policy Approval. If the President accepts the policy, the President will sign and date the approved policy and forward to the General Counsel for dissemination in accordance with the terms of this Policy.

H. Final Procedure Approval. Following completion of the Comment Period the Responsible Executive will incorporate appropriate revisions and forward the revised draft to the General Counsel. Upon legal review and approval, or if no further revisions are required following the Comment Period, the General Counsel will disseminate and publish in accordance with the terms of this Policy and Procedure.

I. Emergency & Interim Policies and Procedures.

1. Interim Policies. As necessary and appropriate, the President may adopt an interim policy pending its final approval pursuant to this Procedure. The Responsible Executive and the General Counsel shall review and approve the draft interim policy for the President’s approval and adoption.
2. Interim Procedures. A Responsible Executive with delegated Presidential authority to enact procedures supporting a policy may adopt interim procedures pending final approval pursuant to this Procedure. The Responsible Executive will forward the draft interim procedure to the General Counsel for legal review and approval, prior to adoption of the interim procedure.
3. Emergency Adoption. When necessary to meet urgent needs or in special circumstances, the President may issue policies without following the procedures set forth in Section II of this Procedure. These circumstances include instances when the University is mandated by federal, state or local law or regulation or action of the Board of Directors, to adopt a new policy.


A. Protocol. New and revised policies and procedures shall be disseminated as follows:
1. Adopted policies and procedures shall be distributed via FSA (current Faculty, Staff & Administrators), via AllStu (if appropriate), and included in the University Policy Webpage, normally within 10 days following adoption.
2. All new and revised policy and procedure releases are to be accompanied by an electronic memo that includes a summary explanation of new or revised material.

B. Policy Manual & University Policy Webpage.
1. The General Counsel will maintain a master policy and procedure manual which will contain the signed copy of each new and revised policy and procedure. The University Policy Webpage will be updated as necessary.
2. Updated versions of the Table of Contents and Index are to be issued with each policy release.
3. Upon adoption of this Procedure, the process of conversion of all existing University policies into the Standard Policy Template will begin. Pending completion of the conversion process, existing policies will appear in their current form, on the University Policy Webpage.
4. Policies and Procedures on the University Policy Webpage are official, and supersede those appearing in other sources.


Responsible Office. From time-to-time, policies and procedures will need to be revised or updated to assure that they remain useful and consistent with applicable laws, regulations, and other policies. The Responsible Office is charged with periodically reviewing and keeping a policy and/or procedure up to date. The Responsible Office will conduct a detailed review of the policy at least once every three years. If the Responsible Office determines that changes to a policy and/or procedure are necessary or prudent as part of the scheduled review or at any other time, the Responsible Office may propose and/or adapt such changes consistent with this Policy and Procedure.

A. Policy Review Components. In addition to a post-implementation review of the effectiveness of the policy and/or procedure, reviews will include:
1. Any changes in regulations or guidance related to the subject matter
2. Known operational systems issues
3. Feedback from compliance training or other sources
4. Clarification of identified ambiguities

B. General Counsel. The General Counsel is authorized to make non-substantive edits and substantive updates to policies that are non-discretionary mandatory changes to accord with other University policies and procedures, state, federal or local law. The General Counsel is also authorized to make similar revisions to University procedures. Non-substantive edits include but are not limited to updating titles or names that may have changed; correcting grammar, punctuation and typographical errors; editing for language consistency and format.