GE0001 – University Policy & Related Procedure Development

Section 1. Policy Statement

This policy establishes a central framework for how the University of Tennessee will identify, create, develop, approve, communicate, maintain, track and update University Policies, Related Procedures and Guidance Documents to promote transparency and compliance across all Policy Documents.  

As further described in this policy, to the extent a Policy Document does not cover a particular Campus need, each Campus within the University will formally set its own procedures and guidance documents.

Section 2. Reason For the Policy

The central framework of this policy will help the University create clear and consistent Policy Documents and enhance overall University and Campus efficiencies.

Section 3. Scope and Application

This policy and its procedures apply to all Policy Documents of the University, including: Fiscal Policies, General Policies, Human Resources Policies, Information Technology Policies, Research Policies, and Safety Policies.  

This policy and its procedures do not apply to: Board of Trustees Policies or Campus academic procedures, including its student and faculty codes and handbooks.  

In general, a Policy Document should be written to: (1) be broad in application to the University, (2) help achieve overall compliance with applicable law or University requirements, (3) increase overall operational efficiencies at the University, and (4) identify and address areas of risk at the University.  University Policies represent the University’s position on a particular subject and set expectations based on the nature and complexity of the subject. Related Procedures represent the specific written actions and practices needed by the University to implement, enforce, administer, and ensure compliance with a particular University Policy where standardization across Campuses is appropriate. Guidance Documents are instructional only and intended to help guide the user to an answer concerning a University Policy or Related Procedure.  

Campus procedures and guidance documents must be consistent with or more restrictive than any applicable University Policy or Related Procedure. In case of any inconsistency, the University Policies shall control, first, followed in order by Related Procedures and then any Campus procedures. Guidance Documents aid with application and interpretation but have no force or effect on University Policy or Related Procedure.

University Policies and Related Procedures are published in the policy website.    

3.1 Responsible Official

The Responsible Official identified for each Policy Document category, in the chart below, shall be responsible for ensuring compliance with this policy and its procedures for their area of responsibility. The Responsible Official may carry out their policy duties through one or more designees and each such designee will be considered a Responsible Official for all purposes under this policy. The Responsible Official may also choose to designate a Policy Document owner for each policy within the Responsible Official’s area of responsibility.  Except for the Senior Policy Review Group, the Responsible Official shall serve as the chair during any policy advisory group approving a Policy Document pursuant to this policy.

If a Policy Document does not address a particular subject area, or if a need is otherwise identified that requires a policy or procedure, a University or Campus member must first contact a Responsible Official to discuss the need and determine whether or not a Policy Document will address the need.  

The following chart lists the Responsible Official, as designated by the President, for each Policy Document category: 


Policy Document CategoriesResponsible Official
1Fiscal PoliciesTreasurer
2General PoliciesGeneral Counsel
3Human Resources PoliciesSenior official designated to oversee human resources
4Information Technology PoliciesSenior official who oversees information technology
5Research PoliciesSenior official who oversees research
6Safety PoliciesSenior official who oversees safety

The President may determine that other Policy Documents, Responsible Officials, or Policy Document categories are necessary due to changes in applicable laws, regulations, or needs of the University, and after such determination by the President, those situations will also be subject to this policy.  

3.2 University Policy Office

The University Policy Office shall reside within the University’s Office of General Counsel and it will oversee the general administration of this policy across the University. The University Policy Office shall be overseen by a director (“University Policy Director”), appointed by the General Counsel. The University Policy Director shall be responsible for ensuring all Policy Documents comply with this policy. The University Policy Office shall be responsible for: 

  • maintaining accurate versions and keeping a complete inventory of Policy Documents,
  • ensuring that Policy Documents are reviewed and updated as required by this policy, 
  • maintaining updated lists of Responsible Officials and any policy committee advisory group rosters
  • overseeing the policy website
  • assisting Responsible Officials with policy routing pursuant to this policy’s procedures, and 
  • developing form templates for University Policies, Related Procedures, and other Guidance Documents.  

3.3 Campus Designated Policy Official

Each Campus must appoint a designated policy official to track and oversee Campus procedures and, for inclusion purposes, to coordinate linking Campus procedures to the University policy website with the University Policy Office. The official must maintain a directory that includes current Campus procedures, guidance documents, and Campus academic procedures, including student and faculty codes and handbooks.   

Section 4. Procedures

4.1. Process for Development and Approval 

All Policy Documents must follow the process outlined in this section. 

Each Policy Document developed must be consistent with or more restrictive than its applicable University Policy. If a Policy Document is in place as of the Effective Date above, then it will remain valid and effective after adoption of this policy. Any subsequent update or technical revision to such Policy Document will be subject to Section 4.3, and any subsequent Policy Document creation, revision, periodic review, repeal, or other Policy Document action must follow the process set forth in this Section 4.

  1. Statement of Need and Impact

When a Responsible Official determines the need to revise an existing, or to develop a new, University Policy or Related Procedure in their area of responsibility, the Responsible Official shall prepare a Statement of Need and Impact for the University Policy Director’s review for compliance.     

4.1.2 Form Templates

All form templates for University Policies and Related Procedures must be created and maintained by the University Policy Office.  

4.1.3 Drafting University Policies or Related Procedures

The Responsible Official may designate one or more subject matter experts to draft a University Policy or Related Procedure.  All such drafts must use the appropriate form template, including the University of Tennessee Policy Glossary and Style Book. Once a draft is complete, the Responsible Official shall submit the draft to the University Policy Office for review.  The University Policy Office shall submit comments to the Responsible Official within twenty-one (21) calendar days, but the Responsible Official may grant an extension of the comment period for good cause. 

4.1.4 Standing Up a Policy Advisory Group For Review

The Responsible Official shall (1) appoint and stand up a policy advisory group which must include, but not be limited to, University and Campus administrators with subject matter expertise in the functional area addressed by the proposed policy, and (2) hold regular meetings of the policy advisory group.  The Chair of the University Faculty Council shall submit to each Responsible Official the nomination of three faculty members (each from a different Campus) to serve on the policy advisory group. The Responsible Official shall appoint one of the nominated faculty members to the policy advisory group.  

The Responsible Official shall submit the completed draft and the Statement of Need and Impact to a standing policy advisory group for review and comment, with a copy to the University Policy Office. The policy advisory group shall submit comments to the Responsible Official within thirty (30) calendar days, but the Responsible Official may grant an extension of the comment period for good cause.  

The policy advisory group may seek the assistance and advice of other subject matter experts, including but not limited to draftees of the policy.  

The Responsible Official shall consider comments by the policy advisory group and, in consultation with the University Policy Office, determine whether the draft requires revision. The Responsible Official may, in their discretion, submit a revised draft to the policy advisory group for review and comment.  A current list of each policy advisory group and its members is located [here]. 

The Responsible Official shall ensure that the chief officer for the relevant subject matter of a policy (i.e.- for Fiscal, Chief Business Officer; for Human Resources, Chief Human Resource Officer, etc.) has the opportunity to review each revised or new policy, either by affirming that the member of the Policy Advisory Group from each Campus has shared it or by sending copies of the revised or new policy directly to the chief campus officer for review.

comment.    

4.1.5 Review and Approval By the Senior Policy Review Group

The Responsible Official shall submit the final policy draft to the University Policy Office and include the following: (a) the Statement of Need and Impact; (b) an executive summary of input by the various reviewing groups; (c) the plan for communicating the policy to affected employees and students, in coordination with appropriate Campus offices, and to any audiences targeted for special communication; and (d) the plan for accomplishing any necessary training. 

After review for compliance, the University Policy Office will submit those documents to the Senior Policy Review Group, which shall consist of the following officials:

  • Senior official responsible for overseeing human resources matters for the University;
  • Chief Financial Officer or senior official responsible for overseeing financial matters for the University;
  • General Counsel; and
  • Chief Audit and Compliance Officer (non-voting).

The Senior Policy Review Group must complete an initial review of the draft, provide comments to the Responsible Official and approve within twenty-one (21) calendar days of submission, but the Responsible Official may grant an extension of the comment period for good cause.     

The Responsible Official, in consultation with the University Policy Office, shall prepare a final version of the draft, incorporating any necessary revisions based on comments by the Senior Policy Review Group. Once finalized, the Responsible Official shall obtain documentation of unanimous approval by the Senior Policy Review Group, which shall include the date of approval. The Responsible Official shall maintain the documentation as a permanent record.  The approval and documentation may be accomplished and maintained electronically, with all record copies being provided to the University Policy Office by the Responsible Official.         

4.2  Communication and Training

4.2.1 Communication to Affected Employees and Students

After the Responsible Official obtains approval of a University Policy or Related Procedure, the University Policy Office shall act with reasonable promptness to have the policy posted on the policy website. If the communication plan approved by the Senior Policy Review Group includes direct communication to affected University or Campus employees and students, the Responsible Official shall act with reasonable promptness, in coordination with appropriate offices, to carry out the communication plan. Direct communication may be accomplished by e-mail, a physical mailing to a last-known home addresses, or social media. Regardless of the method used, the communication must emphasize its relative importance and summarize key provisions of the policy, including key revisions to a previous version of the University Policy or Related Procedure.  

If the Responsible Official knows that a previous version of the University Policy or Related Procedure exists in a printed publication, the Responsible Official shall request the appropriate office to update the publication and to inform the Responsible Official when the update has been accomplished.  

4.2.2 Targeted Communications  

In coordination with appropriate University and Campus offices, the Responsible Official shall determine whether certain groups should be targeted for a special communication about the University Policy or Related Procedure and, if so, implement a plan to accomplish the special communication.        

4.2.3 Training 

In coordination with appropriate University and Campus offices, the Responsible Official shall determine whether all or certain groups of employees need training on the University Policy or Related Procedure and, if so, shall implement a plan to accomplish the training.

4.3  Updates and Technical Revisions

The Responsible Official may work with the University Policy Office to update and make technical revisions, which are administrative in nature, to a Policy Document in their area of responsibility without following the process outlined in Section 4.1.  Examples of updates include the following types of revisions: (1) a threshold amount for competitive bidding; (2) travel reimbursement rates; (3) a threshold amount for approval of entertainment expenses and use of the University’s procurement card; and (4) similar threshold amounts or thresholds. Examples of technical revisions include changes to position titles, contact information, website addresses, spelling and grammatical corrections, and similarly situated  clarifications.  When the revised Policy Document is posted on the policy website, the history must be included.  Updates (but not technical revisions) are subject to the communication provisions of Section 4.2.

4.4  All other Revisions

Any revision to a University Policy or Related Procedure, other than an update or technical revision as described in Section 4.3, must follow the process outlined in Section 4.1.  All proposed revisions must use the “track changes” function unless the changes are so substantial that tracking is impractical, in which case the existing policy must be attached or appended to the revised draft as it advances through the review and approval process.   

For good cause, the President may exempt a particular policy revision from the process outlined in Section 4.1. However, the revised policy remains subject to the approval and communication and training provisions of Section 4.2.   

4.5  Periodic Review  

All University Policies and Related Procedures must be periodically reviewed by the Responsible Official.  Responsible Officials must conduct a review of each University Policy and Related Procedure as needed but no longer than every five (5) years to determine if it requires revision. 

A University Policy or Related Procedure must indicate the last review date and the next regularly scheduled review date on the University Policy or Related Procedure before posting to the policy website.    

4.6  Maintaining Previous Versions 

After the Effective Date of this policy, beginning with the next revision of a Policy Document, the University Policy Office shall maintain an electronic file of all prior versions, including a history section showing the effective date of the original University Policy or Related Procedure, the effective date of all revisions, and a brief description of revisions. 

4.7 Repeal 

If the Responsible Official decides to repeal a University Policy or Related Procedure, the Responsible Official shall present a statement of reasons to the policy advisory group and the appropriate Campus chief officer(s) for comment. If the Responsible Official decides to pursue repeal after considering any comments by the group and the Campus chief officer(s), the Responsible Official shall submit a request for repeal to the Senior Policy Review Group, including a statement of reasons and a summary of comments by the policy advisory group. If repeal is approved, the Responsible Official shall act with reasonable promptness to have the University Policy or Related Procedure removed from the policy website and shall ensure that the last version of the University Policy or Related Procedure, including documentation of its repeal, is maintained as a permanent record, electronically or otherwise with the University Policy Office.        

The provisions of this section will not apply if the General Counsel determines that repeal of a University Policy or Related Procedure is required by law or regulation.  In that event, the Responsible Official shall act with reasonable promptness to remove the University Policy or Related Procedure from the policy website and shall ensure that the last version of the University Policy or Related Procedure, including documentation of its repeal, is maintained as a permanent record, electronically or otherwise with the University Policy Office.   

4.8 Interim Policies 

If circumstances (such as the need to comply with a change in federal or state law or regulations or the existence of a major institutional risk) require that a University Policy or Related Procedure be effective within a time-period that does not allow completion of the procedures outlined in Section 4.1, the Responsible Official may submit an interim draft to the University Policy Office and then to the Senior Policy Review Group. After review by the Senior Policy Review Group, the Responsible Official, in consultation with the University Policy Office, shall prepare a final version of the interim draft, incorporating any necessary revisions based on comments by the Senior Policy Review Group. The University Policy Office shall submit the final version of the interim University Policy or Related Procedure to the Senior Policy Review Group for approval. The Responsible Official shall obtain documentation of approval by the Senior Policy Review Group, which must include the date of approval, and shall maintain the documentation as a permanent record.  The approval and documentation may be accomplished and maintained electronically with the University Policy Office.  

An interim University Policy or Related Procedure will be effective for 12 months, during which the process outlined in Section 4.1 must be completed or revised to become non-interim University Policy or Related Procedure. The Senior Policy Review Group may extend the effectiveness of an interim University Policy or Related Procedure in one or more successive six-month increments, otherwise such interim designation shall expire.

4.9 Websites, Guidance Documents and Printed Publications 

To ensure publication of the most current version of Policy Documents, University and Campus websites and electronic or printed publications should provide a link to the policy website

All Guidance Documents must be provided to the University Policy Office to ensure general consistency and compliance with applicable University Policies or Related Procedures and to update the policy website.    

4.10 Campus Procedures 

Each Campus may adopt a procedure consistent with or more restrictive than this policy if a Campus determines a unique need to develop procedures and guidance documents outside the scope of a University Policy or Related Procedure. To the extent applicable, such outside Campus procedures and guidance documents must include a direct reference to any corresponding University Policy or Related Procedure.  On and after its adoption, the Campus procedure must ensure that the Responsible Official and the University Policy Office review any approved Campus procedure and guidance documents for purposes document control, inventory, and general compliance with this University policy.  

Within one (1) year of the effective revision date of this policy, each Campus must adopt a formal written document that addresses how Campus procedures and guidance documents, as well as Campus student, faculty and academic policies and procedures that are not covered by this policy are formally developed, approved, communicated and maintained. 

Section 5. Definitions

Campus: The University of Tennessee at Chattanooga, The University of Tennessee Health Science Center, The University of Tennessee, Knoxville, The University of Tennessee at Martin, The University of Tennessee Southern, the Institute of Agriculture, the Institute for Public Service, or the Space Institute.

Guidance Document(s): supplementary material such as guidelines, flowcharts, forms, and other means of instruction to assist with compliance and further guide the user to an answer. Guidance Documents must include a direct reference to a University Policy or Related Procedure.

Interim Policy: a provisional policy adopted out of necessity when there is insufficient time to complete the policy development process described in Section 4.

Policy Document(s): one or more University Policies, Related Procedures and Guidance Documents.

Related Procedure(s): the specific written actions, processes and/or practices required by the University to implement, enforce, administer, and ensure compliance with a particular University Policy. Related Procedures may exist independent of or be embedded within a University Policy but all independent Related Procedures must include a direct reference to a University Policy.

Responsible Official: an official designated by the President to be responsible for ensuring compliance with this policy and University Policies within certain categories of responsibilities.  The Responsible Official may carry out the responsibilities of this policy through one or more designees and, as used throughout this policy, the term “Responsible Official” includes such designees.

University: The University of Tennessee.

University Policy or University Policies:  the written University position or set expectation on a particular subject. University Policies may include Related Procedures and Guidance Documents based on the nature and complexity of the subject.

University Policy Director: the policy director appointed by the University General Counsel.  

University Policy Office: the University Policy Office residing within the Office of General Counsel.  

Section 6. Penalties/Disciplinary Action for Non-Compliance

Compliance with this policy may be assessed during any or all assessment activities which includes, but is not limited to, Campus compliance audits, peer reviews, accreditation reviews and external agency reviews. Any Policy Document or Campus procedure or guidance document that does not comply with, or which otherwise conflicts with, this policy shall be superseded by the respective University Policy or Related Procedure.  In such event, the Responsible Official shall reach out to the Campus chief officer to review policy development expectations. In certain situations, failure to comply with this policy may result in inconsistencies and errant expectations that may lead to disciplinary actions.

Section 7. Responsible Official & Additional Contacts

Subject MatterOffice NameTelephone Number (xxx) xxx-xxxxEmail/Web Address
Policy Clarification and InterpretationKatie Lane Office of the General Counsel(865) 974-3245katielane@tennessee.edu
Policy TrainingKatie Lane Office of the General Counsel(865) 974-3245katielane@tennessee.edu

Section 8. Policy History

Version 1: 01/16/2018

Section 9. Related Policies/Guidance Documents

Policy Flowchart; Policy Template; Statement of Need and Impact Template.