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Policy No: 2011
Responsible Office: Office of Compliance
Last Review Date: 02/26/2020
Next Required Review: 11/05/2024

Policy for Policy Development and Maintenance


1. Purpose

This University Policy outlines in general terms the process of proposing, revising, and maintaining Policies at the
University of South Alabama (USA), particularly University Policies, and is intended to ensure they are each
consistent and clarify institutional expectations, are current and available to relevant stakeholders, enhance
efficiency, support the University's compliance with applicable laws and regulations, and connect the University's
mission with its actions.

2. Applicability

This policy applies to any member of the University community involved in developing, proposing, reviewing, revising, maintaining, or publishing University Policies, i.e., those which extend beyond a single Division of the University, and Division Policies, i.e., those limited to a single Division. It does not concern policies that apply only to individual colleges or departments within a Division. Policies that involve federal or regional accrediting agency requirements (e.g., SACS-COC, Clery Act, Title, IV, VI, VII, IX), may be classified as University Policies, even if not initially intended as such, and should be referred to the Policy Committee for Institutional Review.

3. Definitions

Bylaws specify the composition, powers, and operations of specific units or bodies at the University, such as the Board of Trustees, USA Health Medical Staff, and the Faculty Senate.

A Division of the University is any one of the following: Academic Affairs, Development and Alumni Relations, Finance and Administration, Medical Affairs, Research and Economic Development, Marketing and Communications, Student Affairs, Athletics, and the Executive Division.

A Department or Unit is a subdivision or component of a University Division, whose operations are supportive of the Division and possibly also the University.

Institutional Review is the University review process for University Policies.

A Policy is a governing principle that has been formally approved to mandate action or provide direction in the conduct of University affairs.

The Policy Committee is appointed by the President to create and maintain a database for University Policies, evaluate Policies of the University, provide final Policy recommendations to the President, and ensure compliance with the Policy for Policy Development and Maintenance. The Policy Committee shall include the University’s SACS-COC liaison as an ex-officio voting member, the University Registrar, and the University Chief Compliance Officer. In addition, the Committee shall include at least one representative from the following Units: Academic Affairs (an academic Dean in addition to the SACS-COC Liaison), Student Affairs, Faculty Senate (Handbook and Policy Committee Chair), Computer Services Center, Grants and Contracts, Human Resources, Research and Economic Development, College of Medicine, the University Attorney’s Office, and USA Health.

A Policy Facilitator is an individual designated to receive and facilitate the review of Policy proposals and revisions in a Unit of the University. Policy Facilitators are charged with ensuring that Policies conform to institutional templates and receive the appropriate level of review. Policy Facilitators include all University vice-presidents and senior/executive vice-presidents or their designees, the president of the Faculty Senate, and other individuals designated by the University President.

A Unit Policy Manager maintains policies at the Unit or Department level, to include Unit-specific and University Policies originating from the Unit. The role may be formally or informally assigned, and coordinates with Division Policy Facilitators on the occasion of any new or revised University Policies.

A Policy Template sets forth a standardized policy outline, format, header, and naming convention, for consistency.

A Procedure specifies approved actions that facilitate the implementation of a given Policy.

A University Policy has broad application across the University. University Policies extend beyond a single Division of the University, or include regulatory requirements that impact the ability of the University to perform its mission.

A Division Policy applies across all Units or Departments of a single Division.

4. Policy Guidelines

4.1 The procedures stated in section 5.1 will be followed in the development of all new University Policies and any substantive revisions of existing University Policies.

4.2 Current University Policies will be available online via a faculty/staff login, and will supersede any conflicting versions published elsewhere. All prior and superseded University Policies shall be archived to a database accessible by Policy Committee members.

4.3 New University Policy proposals and significant substantive revisions to existing University Policies must conform to the Policy Template (referenced in section 7).

4.4 University Policies are subject to periodic review by the Policy Committee.

4.5 Bylaws of specific units or bodies at the University must be consistent with University Policies. In the event of a conflict between a bylaw and a Policy, the Policy of the University is controlling (excluding Board of Trustees Bylaws).

5. Procedures

5.1 Policy Development and Revision

5.1.1 Proposing Policy Changes or Modifications

Any member of the University community may propose a Policy, or propose that a Policy be revised or discontinued. Community members include students, full and part-time faculty and staff, administrators, trustees, and members of advisory committees or councils at the University. Proposed Policies or Policy revisions should be submitted to the Policy Facilitator for the affected Division. The Policy Facilitator is responsible for ensuring the proposed Policy or Policy revision does not conflict with or supersede any overlapping University Policy, and that it conforms to the Policy Template.

5.1.2 Developing, Approving, and Revising Policies

5.1.2.1 University Policy Development

Proposals for new University Policies must follow the Institutional Review Procedure (see section 5.1.3). The Policy Facilitator of the originating Division shall develop and review the proposed policy in accord with the Policy Template except when otherwise justified. Upon completion of required reviews, the proposed policy must be submitted to the University Policy Committee.

5.1.2.2 University Policy Approval

Once the Policy draft is approved at the Division level (via communication between the Division head (VP) and Policy Facilitator if the same individual does not fill both roles), the draft is forwarded by the Policy Facilitator to the Policy Committee for Institutional Review, in accordance with section 5.1.3.

5.1.2.3 University Policy Revision

The Policy Facilitator shall ensure that University Policies are current. Substantive revisions to existing University Policies must follow the Institutional Review Procedure in section 5.1.3. University Policies which convey regulatory requirements will need to be revised when changes in laws or regulations occur. Minor, non-substantive revisions, particularly revisions that do not affect the scope or intent of the original University Policy, may be made by the head of the responsible Division without following the Institutional Review Procedure of section 5.1.3.

5.1.2.4 Process for Division Policies

Division Policies are reviewed using the originating Division’s procedures for developing, approving, and revising Policies, and are not subject to Institutional Review. If the Policy is approved by the originating Division Head, it is then forwarded to the Division’s Policy Facilitator. The Policy Facilitator is responsible for ensuring the proposed new or revised Policy does not conflict with or supersede any overlapping University Policy, and that it conforms to the Division’s Policy Template.

5.1.3 Institutional Review Procedure

University Policies require Institutional Review. Review steps, with recommended revisions, include:

      • Review by the Division Policy Facilitator;
      • Review by the University Attorney when necessary;
      • Review by the Policy Committee, to ensure that the policy conforms to the Policy Template, is understandable, and is in accord with existing Policies; and
      • Review by all Division heads.

5.1.4 Approval of Institutional Policies

After final review by the Policy Committee, the proposed University Policy is sent with the Committee’s recommendation to the President for final approval. Some policies may also require the review and approval of the University’s Board of Trustees.

The President has the authority to approve interim Policies prior to Institutional Review, for example in response to external mandates, when doing so is in the best interest of the institution.

5.2 Policy Maintenance and Periodic Review

5.2.1 Discontinuance of Existing Policies

Proposals to discontinue University Policies must be sent to the Policy Committee for review by the Division Policy Facilitator. The proposal should include a rationale for the discontinuation of the Policy. The Policy Committee will review the proposal and ensure that discontinuing the Policy will not adversely affect other Policies or the University's compliance with applicable laws and regulations. After review by the Policy Committee, the proposal is sent to the President with the Policy Committee’s recommendation for or against discontinuance for final decision by the President.

5.2.2 Periodic Review of Existing Policies

All University Policies require a review every five years, except where specific accreditation or other external requirements necessitate a more frequent review, or where existing processes for regular revision and review are already in place (e.g., Faculty Handbook, Staff Employee Handbook).

University Policies are reviewed by the Policy Committee for continued relevance and applicability. The Policy Committee may recommend the modification or discontinuance of outdated Policies. In such cases, the recommended changes are evaluated following the Institutional Review Procedure (section 5.1.3 and 5.2.1).

5.2.3 Policy Publication and Storage

All current University Policies will be housed in a policy database and published to an online Policy Library available via a faculty/staff login. Published policies shall conform to the accessibility requirements of the Americans with Disabilities Act and all other applicable laws, rules and regulations.

The Office of Compliance is responsible for overseeing Policy publication. New or revised Policies shall be published solely under the supervision of the Office of Compliance, upon completion of the Institutional Review Procedure.

Any University Policy posted on a USA web page outside the Policy Library, or reference to such Policy, should link to the source Policy in the policy database. Policies should not be copied and pasted to a website, including a University website.

The Office of Compliance shall maintain an archive of discontinued and superseded Policies.

6. Enforcement

The University’s Chief Compliance Officer is responsible for this policy, with support by the University Policy Standing Committee. Noncompliance with this policy will be addressed by the Chief Compliance Officer.

7. Related Documents

7.1 University Policy Template.