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.
Administration – 1 policy – This policy has been signed and is effective immediately during the 30 day comment period.
Policy Name: 3364-5-14 Expression on campus
Description: Major revision specifies no activity may damage university property including grass
or landscaping; as well as adding section (E)(4) stating no tents or structures, permanent
or temporary, may be erected anywhere on campus unless approved in writing by the
university prior to the date of this policy revision.
Scope: All University of Toledo Campuses
Comment Period: April 25, 2024 through May 28, 2024
Comment on this policy: 3364-5-14
College of Medicine and Life Sciences – 4 policies
Policy Name: 3364-81-04-06-01 Supervision and teaching of medical students
Description: Major revisions. Changes made include: policy statement – teaching responsibilities
from the classroom to outpatient and inpatient clinical settings; procedure – state
how educators must be provided with the knowledge, skills, and training to fulfill
their roles and responsibilities to supervise medical students. Clinical teachers
must sign an attestation form. The policy outlines definitions of the types of observation,
how observed, and how the delegation of responsibility is handled. Also outlines
how students will be observed in inpatient, outpatient and surgical sites.
Scope: MD Program, College of Medicine and Life Sciences
Comment Period: April 19, 2024 through May 20, 2024
Comment on this policy: 3364-81-04-06-01
Policy Name: 3364-80-04-034-00 Administration of proctored/written and/or computer examinations
in the MD program
Description: Minor revisions. Scope was modified. Expectations of the examinee are clearly defined
- noting how late arrivals will be handled, what Items are allowed in the exam room
and how disruption of the test environment and behavior will be handled.
Scope: MD Program, College of Medicine and Life Sciences
Comment Period: April 19, 2024 through May 20, 2024
Comment on this policy: 3364-81-04-034-00
Policy Name: 3364-81-16 Formative feedback during foundational science curriculum
Description: Minor revisions in the policy statement identify who is responsible for providing formative feedback.
Scope: MD Program, College of Medicine and Life Sciences
Comment Period: April 19, 2024 through May 20, 2024
Comment on this policy: 3364-81-16
Policy Name: 3364-81-24 Narrative descriptions of performance during the foundational science and
clinical curriculum
Description: Minor revisions include when narrative will be provided and omission of laboratory
sessions..
Scope: MD Program, College of Medicine and Life Sciences
Comment Period: April 19, 2024 through May 20, 2024
Comment on this policy: 3364-81-24
Graduate Medical Education – 1 policy
Policy Name: 3364-86-025-00 Resident supervision
Description: Minor revisions. Added to policy - Faculty and other members of the healthcare team can view a resident
or fellow’s privilege levels and any time via ePriv (ProMedica) or iPriv (UTMC).
Any procedure or treatment that requires informed consent - e.g. residents and fellows
will follow the informed consent process as per the institutional/facility policy
in which they are practicing; intimate exams – procedural consent must be obtained
in all circumstances and clearly documented in the medical records per institutional/facility
policy. Preoperatively, patients are to be told who is participating in the surgery
and provide at least verbal permission for participation. Anesthetized patients are
not to undergo additional sensitive location exams (e.g.: pelvic exams, rectal exams,
breast exams) by learners uninvolved with the actual performance of the procedure.
Those directly involved in the care of the patient may only perform sensitive location
exams if it is required as part of the procedure itself or to assess procedural technical
success. Consent for performance of sensitive location exams should be obtained prior
to the onset of anesthesia.
Scope: MD Program, College of Medicine and Life Sciences
Comment Period: April 19, 2024 through May 20, 2024
Comment on this policy: 3364-86-025-00
Patient Financial Servicies (UTMC) – 1 policy – This policy has been signed and is effective immediately during the 30 day comment period.
Policy Name: 3364-142-13 Patient financial assistance
Description: Major revisions as noted by red-line in the proposed policy.
Scope: UTMC
Comment Period: May 3, 2024 through June 3, 2024
Comment on this policy: 3364-142-13
COLLEGE OF MEDICINE and LIFE SCIENCES – 2 policies
Policy Name: 3364-81-04-013-02 Academic promotion, grading criteria, remediation, dismissal in
the MD program
Description: Minor revisions. Remove option to appeal to the Dean; clarifying statement for what
a student in good standing reflects; remove communication of grades in the syllabus;
remove score requirements on the NBME since the NBME exams are now becoming part of
the end of system summative assessment; remove language on monitoring by APC since
this language is in another policy; revised failed examination language and remediation.
Throughout the policy, there are many grammatical and title revisions.
Scope: College of Medicine and Life Sciences
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-81-04-013-02
Policy Name: 3364-81-12 Curriculum modification
Description: Minor revisions. Revisions clarify that ECC must review and approve curriculum changes;
that ECC will provide formal updates to COMLS council; and any major changes made
will be discussed at council and ultimate authority lies with ECC.
Scope: College of Medicine and Life Sciences
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-81-12
GRADUATE MEDICAL EDUCATION – 5 policies
Policy Name: 3364-86-002-00 Implementation of new programs or instituting change in existing programs
Description: Minor revisions. The committee will consist of equal member representation as designated
by the Dean of the COMLS and ProMedica CEO. The DIO will serve as a member of the
committee.
Scope: UT College of Medicine Residency Programs
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-002-00
Policy Name: 3364-86-019-00 Resident eligibility for graduate medical education at the University
of Toledo
Description: Minor revision to wording in the procedure section.
Scope: UT College of Medicine Residents
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-019-00
Policy Name: 3364-86-021-00 Graduate medical education committee
Description: Minor revisions. The committee should include two peer selected program coordinators
who will serve a two-year term. Change to meeting frequency, notification of recording
of meetings for purposes of taking minutes only. Required meeting attendance listed.
Scope: UT College of Medicine Residency Programs
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-021-00
Policy Name: 3364-86-038-00 Educational rotations outside of the University of Toledo and affiliated
hospitals/clinical sites
Description: Minor revisions. Educational rotations required by a program’s RRC, that all residents/fellows
must have experience in and are not available at UT/affiliated hospitals are not considered
outside rotations and are not applicable to this policy.
Scope: UT College of Medicine Residents
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-038-00
Policy Name: 3364-86-041-00 Multidisciplinary pain medicine fellowship management
Description: Minor revision. The committee will regularly review the program’s resources and its
attainment of stated goals and objectives.
Scope: UT College of Medicine Residency Program
Comment Period: May 15, 2024 through June 14, 2024
Comment on this policy: 3364-86-041-00