UT Health Science Center

UT Health Science Center Handbooks & Procedures


Campus Procedure Contact: Melanie Burlison, mburlison@uthsc.edu

View all UTHSC Handbooks and Procedures (by subject) and descriptions

University of Tennessee Health Science Center Procedures

ED400 – Sexual Harassment, Sexual Assault, Dating Violence, Domestic Violence, and Stalking
A118-H Transfer Credit Policy – Student Procedure
AA100-H Attendance Policy
AA101-H Credit Hour Policy – Academic Affairs
AA102-H Distance Education and Off-campus Instructional Sites Policy – Academic Affairs
AA103-H Certificate Policy – Academic Affairs
AA104-H Continuing Education Policy
AA105-H Course Numbering Policy – Academic Affairs
AA106-H Credit for Prior Learning Policy – Academic Affairs
AA107-H Curricular Changes Relating to Academic Programs – Academic Affairs
AA108-H Student English Language Proficiency – Academic Affairs
AA109-H General Education Requirements Policy – Academic Affairs
AA110-H Grading Policy – Academic Affairs
AA112-H Foreign Nationals Policy
AA113-H Program Review Requirements – Academic Affairs
AA114-H Scheduling of Academic Pace and Ad Hoc Activities Procedure – Academic Affairs
AA115-H Credit by Examination Policy – Academic Affairs
AA116-H UTHSC Substantive Change Policy
AA117-H Repeat Course Policy
AA118-H Transfer Credit Policy – Student Procedure
AA119-H Recording of Faculty Lectures
AA120-H Recognition of Accreditors
AC-001 – Access Control
AC-001.02 – Privileged Account Management
AC-001.04 – VPN Access
AC-001.06 – Third-Party Access to Account and Data
AC-001.08-Data Center Access
AC-002 – Authentication
AC-002.02 – Password Management and Complexity
AC-002.04 – Net ID Account Management
AD100-H Procedure for Compliance with Drug Free Campus
ADM0001-H Commissioning of Police Officers – Campus Police
ADM0002-H Protocol on Major Disturbances and Violent Crimes – Campus Police
ADM0003-H Security Information Act – Campus Police
ADM0004-H ID Card/Card Reader System and Key Control
ADM0100-H Parking – Parking Services
ADM0200-H Facilities
ADM0201-H Motor-Pool – Facilities
ADM0300-H Leadership Institute – Administration
ADM0301-H Appointment to Endowed Professorship or Chair of Excellence
AT-001 – Training and Awareness
AU-001 – Auditing & Logging Accountability
AU-002 – Logging and System Activity Review
C0128-H Campus Wide Training Approval
CM-001 – Configuration Management
CM0001-H Advertising
CM0002-H Email Signatures and Photos
CM0003-H Interior Building Graphics
CM0004-H Logo Usage
CM0005-H Media
CM0006-H Social Media
CM0007-H Stationery, Publications, and Printing
CM0008-H Headshots
COHP101 Curriculum Committee – Academic Policy
COHP102 Academic Faculty Mentoring Guidelines – Academic Policy
COHP103 Credit Hour – Academic Policy
COHP104 Distance Education and Off-Campus Instructional Sites Policy – Academic Policy
COHP105 Grading Policy – Academic Policy
COHP106 Waiver and/or Substitution Request – Academic Policy
COHP107 Supervision of Student on Clinical or Fieldwork Assignment – Academic Policy
COHP108 Student Scholarship Award Guidelines – Academic Policy
COHP109 Honors Designation at Graduation – Academic Policy
COHP110 Admissions Policy – Academic Policy
COHP111 Withdrawal Policy – Academic Policy
COHP112 Progress, Promotion and Academic Appeal Policy – Academic Policy
COHP113 Immunization Policy – Academic Policy
COHP114 Faculty Workload Policy – Academic Policy
COHP115 Adjunct Teaching Recruitment and Evaluations Policy – Academic Policy
COM-G02 Student Complaint Logs (Guideline) – COM Medical Education
COM-G04 M3 Examination Procedures (Guideline) – COM Medical Education
COM-G05 -Responsibilities for Preclinical Courses (Guideline) – COM Medical Education
COM-GS01 Student Workload in the Pre-Clinical Curriculum – COM Medical Education
COM-G03 Student Video Platform Etiquette (Guideline) – COM Medical Education
COM101 Continuous Quality Improvement – COM Medical Education
COM102 Credit Hour Determination – COM Medical Education
COM103 Student Immunizations – COM Medical Education
COM104 Visiting Students – COM Medical Education
COM105 Progress, Promotion and Graduation with a Doctorate of Medicine (M.D.) – COM Medical Education
COM106 Excused Absence and Wellness Days – COM Medical Education
COM107 Grading for the MD Curriculum – COM Medical Education
COM108 Student Mistreatment – COM Medical Education
COM109 Orientation of Resident and Non-Faculty Instructors in the Pre-Clerkship Phase – COM Medical Education
COM110 Provision of Narrative Feedback to Medical Students – COM Medical Education
COM111 Media Capture of Live-Lecture Sessions in the Pre-Clerkship Phase – COM Medical Education
COM112 Work Hours – COM Medical Education
COM113 Reinstatement to the COM – COM Medical Education
COM114 Clinical Supervision of Medical Students – COM Medical Education
COM115 Student Feedback and Course Evaluation Completion – COM Medical Education
COM116 Inclement Weather – COM Medical Education
COM117 Infection Control and Prevention of Exposure to Environmental Hazards – COM Medical Education
COM118 Reporting Infections and Other Hazard Exposures – COM Medical Education
COM119 Anti-Discrimination – COM Medical Education
COM120 Committee Composition and Procedures – COM Faculty Affairs
COM121 Professionalism – COM Medical Education
COM122 Confidentiality and Conflict of Interest – COM Admissions
COM123 COA Subcommittees and Procedures – COM Admissions
COM124 Appearance Code for Simulated and Clinical Experiences – COM Medical Education
COM125 Procedures to Ensure Timely Submission of Summative Assessments – COM Medical Education
COM126 Faculty Participation in Outside Residences – COM Faculty Affairs
COM127 Re-attestation to Meet COM Technical Standards – COM Medical Education
COM128 Consent for Exams Under Anesthesia – COM Medical Education
COM129 – Provision of Formative Assessment and Feedback to Medical Students in the Pre-Clinical Phase – COM Medical Education
COM130 Excused Absence Policy for Preclinical Curriculum – COM Medical Education
COM131 Death of a COM Student – COM Medical Education
COHP116 – COHP Emergency Suspension of Operations on Campus – Academic Policy
COVID-19 Contingency Plan
COVID-19-H Telecommuting
CP-001 – Business Continuity Planning
CP-002 – Information Security during a Disaster
CR001 – Continuing Review of Research
CR002 – Review of Revisions in Approved Studies
CR003 – Study Closure and Record Retention
CS-001 – Device Life Cycle Security
CS-002 – Personally Owned Device Security
DBD001 – Drug Biologic and Device – Emergency Use
DBD002 – Drug, Biologic Device – Significant Risk/Nonsignificant Risk Determinations for Medical Device Studies
DBD003 – Drug, Biologic Device – Humanitarian Use Devices (HUD)
DBD004 – Drugs, Biologics and Devices – Compassionate/ Treatment Use of Drugs, Biologics and Devices Under the FDA Expanded Access Program
EC5400 – Hazardous Waste Disposal
ED100 – Diversity Statement Policy
ED200 – Discrimination Complaint Procedure
ED300 – Search Procedures: Guidelines for Conducting Academic and Staff-Exempt Searches
ED400 – Sexual Harassment, Sexual Assault, Dating Violence, Domestic Violence, and Stalking
EM100 Annual Comprehensive FERPA Notice for Students
EM101 Course Add Drop Policy
EM102 – Criminal Background Checks for Matriculating Students
EM103 Academic Calendar Policy
EM104 Withdrawal Policy
EM105 Reinstatement Policy
EM106 Visiting Student Procedure
EM107 Attendance in Courses Pending VA Payment Policy
EM108 Awarding of Degrees
EM109 Effective Date of Student-Related Policies
EM111 Student Death Procedures
EM112 – Student Status During Academic Appeals
EM113 – Eligibility Verification Policy
EM117 – Guidelines for Treatment of Student Payments
EM118 – Satisfactory Academic Progress
EM119 – Catalog Year and Continuous Enrollment
EM120 – Academic Standing
EM121 – Return of Title IV Funds
EM122 – Exit Counseling
EM123 – Federal Work Study Policy
EM124 – Financial Aid Verification Policy
EM5502 – Emergency Action Plans
EXPORT100 – UTHSC Export Control Policy
FA100 Adjunct Faculty Appointments at Other Institutions Policy
FA101 UTHSC Distinguished Professor Policy
FA103 Documentation and Recognition of Faculty Credentials
FA105 Volunteer Faculty Policy and Procedures
FA106 Certification of Effective Communication in English for Faculty
FA107 Faculty Educational and Development Leave Policy
FI0120-H Records Management
FI0120a-H Records Management Instructions and Forms
FI0120b-H Records Management Inventory and Retention Form
FI0125-H Conflict of Interests
FI0126-H Conflict of Interests (Interactions Between Health Care Professionals and Industry)
FI0130-H – Fraud, Waste, and Abuse
FI0135-H – Insurance
FI0140-H Unclaimed Property
FI0145-H – Service and Recharge Centers
FI0150-H – Approvals
FI0200-H – Faculty Incentive Program – Sponsored Projects
FI0220-H – Cost Transfer Explanation Form
FI02050-H – Sponsored Projects
FI0250a-H – Request for Reallocation of Training and/or Research Grant Funds
FI0250b-H – Residual Supplies Inventory Form
FI0305-H – Accounts Receivable
FI0306-H – Procedure for Delivery of Credit Balance – Student Procedure
FI0307-H – Right to Cancel Notification Procedure – Student Procedure
FI0320-H – Indicia Licensing, Promotions, and Sponsorships
FI0325-H – Vending and Solicitations on Campus
FI0405-H – Procurement – Fiscal Procedure
FI0420-H – Service Contracts
FI0430-H – Receiving Materials
FI0435-H – Memberships and Subscriptions
FI0445-H – Employee Services Between UTHSC and State Institutions or Agencies
FI0450-H – Moving Expenses
FI0475-H – Salary Advance
FI0505-H – Accounts Payable – Fiscal Procedure
FI0525-H – Petty Cash
FI0525a-H – Petty Cash Standards for Security of Petty Cash Funds (Attach A)
FI0525b-H – Petty Cash Security Review Form (Attach B)
FI0605-H – Equipment
FI0610-H – Surplus Property
FI0705-H Travel
FI0715-H – Entertainment – Fiscal Procedure
FI0720-H – Retirement Reception
FI0730-H Wireless Equipment Allowance
FS5300 – Fire Prevention Plan
FS5301 – Building Fire Watch Policy
FS5302 – Portable Fire Extinguisher Policy
FS5303 – Hot Work Policy
GP-001-UTHSC – Information Security Program
GP-001.01 – Information Security Roles and Responsibilities
GP-001.02 – Security Exceptions and Exemptions to ITS Standards Practices & Controls
GP-001.04 – Information Security Violations
GP-002 – Data & System Classification
GP-003 – Expectation of Privacy
GP-004 – Acceptable Use of IT Resources
GP-004.01 – Login Banner
GP-004.02 – Acceptable Use of Generative AI
GP-004.03 – Acceptable Use of UTHSC Phones and Service
GP-005 – Data Security
GP-005.01 – Disposal or Destruction of Electronic & Non-Electronic Media
GP-006 – Email
GP-007 – Asset Management
GP-007.02 – Antivirus Antimalware Protection
GS050 – Personal Protective Equipment
GS135 – Ariel and Scissor Lift Procedures
GS5101 – Forklift Safety Policy
GS5102 – Ladder Safety Policy
GS5103 – Lock Out Tag Out Safety Policy
GS5104 – Motor Vehicle Safety Policy
GS5105 – Respiratory Safety Protection Policy
GS5107 – Slips, Trips and Falls Safety Policy
GS5108 – Unmanned Aircraft Systems Policy
GS5110 – Smoke Free Campus
GS5111 – Contractor Safety Program and Guidelines
GS5112 – Contractor Safety Procedures Manual
GS5113 – Electrical Safety Procedure
GS5114 – Safety Training Procedure
GS5115 – Emergency Eyewash and Safety Showers
GS5116 – Confined Space Written Program
GS5117 – Fall Protection Program
GS5200 – Exposure Control Plan 2022
GS5300 – Instructional Lab Safety Program
H110 – Confidentiality of Protected Health Information
H115 – Safeguards for Protected Health Information
H120 – Patient Health Records
H125 – Notice of Privacy Practices
H126 – Notice of Privacy Practices (English)
H127 – Notice of Privacy Practices (Espanol)
H130 – Education and Training on Patient Privacy
H135 – Breach Notification
H140 – Business Associate Agreement
H141 – UTHSC Standard Business Associate Agreement
H200 – Use of Social Media – Patient Privacy
H210 – Patient Photography, Videotaping, and Imagery
HM5100 – Hazard Communication Program
HM5200 – Compressed Gas Policy
HM5201 – Regulated Medical Waste Policy
HM5202 – Controlled Substances Policy
HM5203 – Hazardous Waste Management
HM5204 – Waste Reduction Plan
HM5205 – Formaldehyde Exposure
HM5206 – Hazardous Material Security Plan
HM5207 – Hazardous Material Spill Contingency Plan
HM5208 – Contingency Plan Quick Reference Guide for Central Hazardous Waste Accumulation Areas (CHWAA’S)
HR0110-H – Employment of Minors
HR0120-H – Retired Employees
HR0125-H – Employee Clearance and Exit Interviews
HR0128-H – Human Resource Development
HR0129-H – The University of Tennessee Health Science Center Performance Review Process
HR0130-H – Personnel Files and Release of Information
HR0130b-H – Official Employee Personnel File Content
HR0135-H – Probationary Period
HR0143-H – Employment Procedure-Exempt and Non-Exempt Temp Pool
HR0143a-H – Faculty Recruitment & Appointment Procedure
HR0145-H – Reduction in Force
HR0150-H – Restoration in Force
HR0160-H – Termination
HR0220-H – Equal Employment Opportunity
HR0280-H – Sexual Harassment
HR0305-H – Annual Leave
HR0310-H – Continuous Service Credit
HR0315-H – Court Leave
HR0320-H Administrative Closing and Inclement Weather
HR0330-H – Educational Assistance (Fee Waiver)
HR0331-H – Educational Assistance (Spouse and Dependents)
HR0335-H – Educational Leave
HR0339-H – Parental Leave
HR0340-H – Funeral and Bereavement Leave
HR0345-H – Group Insurance
HR0350-H – Holidays
HR0355-H – Leave of Absence
HR0360-H – Leave Transfer
HR0370-H – Military Leave
HR0373-H – Personal Leave
HR0375-H – Retirement Plans
HR0380-H – Sick Leave
HR0382-H – Sick Leave Bank
HR0390-H – Tax Deferred Income Program
HR0395-H – Time Off To Vote
HR0397-H – Workers Compensation
HR0430-H – Job Classification
HR0432-H – Longevity Pay
HR0445-H – Overtime
HR0455-H – Pay Rates
HR0460-H – Spot Bonus
HR0465-H – CAP Exam
HR0472-H – Supplemental Pay
HR0480-H – Work Schedules
HR0485-H – Hybrid and Remote Work Arrangements
HR0525-H – Disciplinary Actions
HR0580-H – Code of Conduct
HR0610-H – Limited Duration Appointment
HR0630-H – Employee Relations Advisory Organizations
HR0640-H – Grievances
HR0720-H – Drug Free Campus Workplace
HR0820-H – Professional Attire
IA100 – International Travel Requirements
IACUC100 – Animal Transportation Policy
IACUC110 – Animal Treatment Concerns
IACUC120 – Executive Committee Role
IACUC130 – Mouse and Rat Toe Clipping Policy
IACUC140 – Murine Tail Biopsy Policy
IACUC150 – Rodent CO2 Euthanasia Policy
IBC100 – Additional Guidelines for the Transfer of Recombinant DNA Molecules into Human Subjects
IBC110 – Condensed Description of Biosafety Levels
IBC120 – General Guidelines – IBC Research
IBC130 – IBC Charter
IBC140 – Simplified Guidelines for Recombinant DNA Research
IC001 – Informed Consent and Confidentiality – Certificates of Confidentiality
IC002 – Informed Consent and Confidentiality – HIPAA Authorization
IC004 – Informed Consent and Confidentiality – Informed Consent of Non-English Speaking Subjects, Illiterate English-Speaking Subjects, and Visually-Impaired or Hearing-Impaired English-Speaking Subjects
IC005 – Informed Consent and Confidentiality – Use of Protected Health Information Without Subject Authorization
IE100 – Student Learning Assessment
IH010 – Hearing Conservation Program
IR-001- Security Incident Response
IRBREV001 – IRB Review – Case Studies/Reports
IRBREV002 – IRB Review – Conducting International Research
IRBREV003 – IRB Review – Criteria for IRB Approval of New Research Applications
IRBREV004 – IRB Review – Expedited Review of New Studies
IRBREV005 – IRB Review – Authority, Membership, and Permanent Positions
IRBREV006 – IRB Review – NHSR Status for the Use of Selected Commercial Vendors and Specimen & Data Repositories
IRBREV007 – IRB Review – Determination of NHSR or Exempt Status
IRBREV008 – IRB Review – Procedures for Full Board Review
IRBREV009 – IRB Review – Use of Anonymized Human Cell Lines
IRBREV010 – IRB Review – Member Education
IRBREV011 – IRB Review – Utilization of Cooperative Agreements
ITS-GP-001 – Standard on UTHSC Information Technology Standards and Practices
ITS-GP-001.01 – Framework for Developing Standards and Practices
L501 – Laser Safety Program
LACU100 – Access to Animal Facilities
LACU120 – USDA Categories
LACU130 – Use of Personal Protective Equipment (PPE) in Animal Facilities
LACU140 – UTHSC Mouse Cage Density Policy
LACU150 – UTHSC Rat Housing Policy
LACU160 – UTHSC Use of Drugs in Animal Experimentation
NRP01 – Non-Ionizing Radiation Program
PE-001 – Physical Security of Information Resources and Related Facilities
PS-001 – Personnel Security
REGCOMP001 – Regulatory Compliance – Responsibilities of Investigators
REGCOMP002 – Regulatory Compliance – Appeal of IRB Decisions
REGCOMP003 – Regulatory Compliance – Auditing of Research Studies
REGCOMP004 – Regulatory Compliance – Conflicts of Interest
REGCOMP005 – Regulatory Compliance – Responsibilities of Investigators
RES100 – Animals in Research
RES110 – Assurances of Compliance with Federal Regulations
RES120 – Compliance with Federal and State Regulations for Controlled Substances and Legend Drugs
RM-001 – Risk Management
RM-001.01 – Risk Assessment Process
RM-002 – Vulnerability Management
RM-003 – Patch Management
RM-004 Third Party Risk Management
RS001 – Chemical Hygiene Plan
RS002 – Exposure Control Plan
RS003 – Laboratory Safety Inspections
RS101 – Minors in Laboratories
RS102 – Incident Reporting
RS103 Accident-Incident Investigation
RS104 Laboratory Closeout
RS105 – Procedure for New Laboratories
RS106 – Use of Extension Cords and Surge Protectors
RS202 – Controlled Substances in Research
RS203 – Critical Freezer Inventory and Audit
RSP00 – Organization of the Radiation Safety Program
RSP01 – Enforcement of the Radiation Safety Program
RSP02 – Security of Radioactive Materials
RSP03 – Laboratory Survey Procedure
RSP05 – Use of Radioactive Materials in Animals
RSP07 – Safe Use of Radioactive Materials
RSP08 – Registration and Inspection of X-Ray Machines
RSP09 – Portable Radiation Survey Instrument Calibration and Use
RSP10 – Radioactive Waste Guidelines
RSP11 – Decay in Storage
RSP12 – Transport of Radioactive Materials on Campus Radiation Safety.docx
RSP14 – Use of X-Ray Equipment
RSP21 – General Licensed Device Management
RSP22 – Radioactive Materials Procurement
RSP25 – Radioactive Materials Spill Response
SA00120 Alcohol Policy
SA105 – Preventing Student Mistreatment
SA107 – Accommodations for Religious Beliefs Practices and Observances
SA110 – Student Complaint Procedure
SA116 – Student Substance Use Policy
Safety Committee Charter
SC-001 – Network Security
SC-001.02 – Network Security Infrastructure
SC-002 – System and Communication Protections
SC-002.01 – Official Communications Use & Protections
SC-003 – Application System Security
SC-003.02 – Application System Security Features
SC-004 – Wireless Network Security
SC-005 – Encryption
SC-005.02 – Encryption for Mobile Computing and Storage Devices
SC-006 – Internet Of Things Security
Security Plan for the Transportation of Hazardous Materials
SIM100 – Sim Confidentiality Policy
SIM101 – Sim Scheduling Policy
SIM102 – Sim Curriculum Development Policy
SIM103 – Sim Attire Policy
SIM104 – Sim Media Capture Policy
SIM105 – Sim Faculty/Facilitator Responsibilities
SIM106 – Remediation and Practice
SIM107 – Sim Physical and Psychological Safety
SIM108 – Sim Equipment, Supplies-Maintenance
SIM109 – Sim Equipment, Supplies-Separation
SIM110 – CHIPS Tour
SIM111 – SIM CHIPS Access
SIM112 SIM Standard Patient (SP) Breaks
SIM113 – SIM Learner Evaluation of Activity
SIM114 – Sim Equipment – Storage
SIM115 – Sim Equipment, Supplies-Loan
SIM116 – Student Sim Requests
SIM117 – Professional Development
SIM119 – Makeup and Delayed Events
SIM121 – Faculty/ Facilitator Orientation
SPACE100 – Allocation of Research Space 2016
SRP001 – Review of Progress and Safety Reports, Other Than Reports of Unanticipated Problems
SRP002 – Safety Reports & Protocols – Reporting Unanticipated Problems Including Adverse Events
SRP003 – Safety Reports & Protocols – Protocol Waivers and Deviations
UTHSC Radiation Safety Committee – Authority, Functions, and Membership
VPOPUL001 – Vulnerable Populations in Research – Review of Research – Additional Protections for Children
VPOPUL002 – Vulnerable Populations in Research – Additional Protections for Prisoners
VPOPUL003 – Vulnerable Populations in Research – Additional Protections for Vulnerable Subjects – Pregnant Women and Fetuses

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