Policy procedures

School of Medicine policy and procedure documentation

Proposed new and updated School of Medicine (SOM) policies are drafted by the initiating administrative department/unit.  Following review by the department/unit's supervisor and approval by the Vice Dean, the proposed or modified policies will be sent to the Office of the Dean for review and approval. Only the Dean is authorized to approve new or updates School of Medicine policies.

The proposed additions or changes to the SOM's policies are reviewed for compliance with other university policies and procedures as well as existing regulations within respective departments/units as it relates to the subject matter. The proposed changes to the SOM's policies are presented to the Council of Vice Deans for review and discussion. The proposed changes may be provided to the Executive Council of the Faculty Senate for input and advice, where appropriate.

Changes to the SOM's policies may require review by the Office of the Vice President for Health Affairs, the Provost or his/her designee, and/or General Counsel. Once approval by the Dean is signed, the online version of the new or updated policy is updated and hard copies are distributed to authorized university departments.

The online version of the SOM policies is maintained by the Office of the Dean.


The SOM's policies and procedures are documented online by the Office of the Dean in the same prescribed format as the university's Administrative Policy and Procedure Manual (APPM).

New and revised policies and procedures are effective once approved by the Dean of the SOM or his/her designee.


Responsibility Action

Initiating Department/Unit

  1. Draft proposed policy and procedure in proper format. (See APPM section)
  2. Forward draft to the initiating department/unit's supervisor, when appropriate and, if applicable, the Vice Dean responsible for the initiating unit.
  3. Then forward to the Office of the Dean.
  4. If necessary, forward to the Office of the Vice President for Health Affairs, the Provost and/or General Counsel.

Sequentially, the Vice Dean, Dean, and VP for Health Affairs and/or the Provost

  1. Review proposed policy and procedures.
  2. Advise originator of any concerns on content and make recommendations to comply with documentation guidelines.
  3. Issue the draft only to those departments concerned with subject matter for review and comment.

Reviewing Departments

  1. Review for conformity and compliance with departmental requirements.
  2. Note conflicts, alternatives and any oversights.
  3. Return to the Vice Dean responsible for the initiating department.

The Vice Dean responsible for the initiating department

  1. Coordinate responses and develop final draft.
  2. Issue to all departments concerned with subject for review and comments.

Initiating/Reviewing Departments

  1. Review, comment and sign draft.
  2. Return signed draft to the Vice Dean responsible for the initiating department.

The Vice Dean responsible for the initiating department

  1. If no further comments are to be considered for approval, forward to both the Council of Vice Deans and the EC of the Faculty Senate for review.
  2. Consult with departments involved to coordinate a resolution of any differences:
    1. Revise draft accordingly.
    2. Resubmit to all concerned to review for concurrence.
  3. Revise draft as recommended during the approval process.
  4. Issue upon authorization by the Dean.