POLICY UPDATES - 2008

The following revised and/or new policies have been posted to the University Policy Web Site.  The links under the headings "ACTION" and "POLICY NUMBER " are operational for only the most recent updates.  For questions concerning policy content please contact the appropriate department. 
MONTH-YEAR/POLICY
ACTION
POLICY NUMBER
June 2008 (month posted)    

Select Biological Agents & Toxins and Biosafety Level 3 Laboratories, Amended on May 20, 2008

Revised with Substantive changes.

Purpose:

The purpose of this policy is to: (a) ensure that select biological agents and toxins are handled safely and secured properly, (b) establish procedures to promote the safe operation of Biosafety Level 3 laboratories, and (c) provide a safe and secure environment for faculty, staff, students, visitors, patients, and the surrounding community.

This policy establishes procedures and requirements that will facilitate the University’s compliance with the Centers for Disease Control (CDC) and United States Department of Agriculture (USDA) regulations entitled: Possession, Use, and Transfer of Select Agents and Toxins: Final Rule (42 CFR parts 72 and 73, 7 CFR Part 331, and 9 CFR Part 121) as well as all other applicable laws and regulations relating to select biological agents and Biosafety Level 3 (BSL-3) laboratories .

Highlights:

  1. Title changed from Possession by Restricted Persons of Select Biological Agents or Toxins to Select Biological Agents & Toxins And Biosafety Level 3 Laboratories
  2. Purpose has been expanded to include the Centers for Disease Control and United States Department of Agriculture regulations entitled: Possession, Use, and Transfer of Select Agents and Toxins: Final Rule (42 CFR parts 72 and 73, 7 CFR Part 331, and 9 CFR Part 121).
  3. Applicability has been changed to include University schools and units acquiring, possessing, utilizing, transferring or otherwise having access to select agents and toxins as well as any school or unit owning, operating or occupying a BSL-3 laboratory facility.
  4. Requirements for approval to obtain, use or otherwise have access to select agents and toxins were added to the policy.
  5. The steps for approval to use University owned, operated, and/or occupied select agent and BSL-3 laboratories were added to the policy.
  6. Procedures for registration of select agent research were revised in the policy.
  7. Stipulated that each select agent and BSL-3 laboratory must have a clearly identified facility director and facility manager. Duties for each position are outlined.
  8. Incidents and near-miss incidents must be reported to the appropriate UMDNJ authorities.
  9. Each select agent and BSL-3 facility is required to be overseen by a Risk Assessment Committee.
  10. The “ Select Biological Agents and Toxins Compliance Program” has been added as Appendix A.
  11. The “Biosafety Level 3 (BSL-3) Laboratory Compliance Program” has been added as Appendix B.

Review/Approval Process

EMOHS coordinated the review with all appropriate schools, units, and CA departments. The policy was approved by the UMDNJ Board of Trustees at the May 20, 2008 meeting.


May 2008 (month posted)    

Sanctions for Late Appraisals

As of April 30, 2008 this policy has been reclassified and transferred. 

This policy establishes procedures to promote timely performance evaluations by managers and specify corrective actions for those who fail in fulfilling this responsibility.  Since the Department of Human Resources has the sole accountability for articulating and implementing the various provisions and associated procedures pertaining to this matter, this policy will be maintained henceforth at the Human Resources site: http://www.umdnj.edu/hrweb/policies/pl206000.pdf 

Reclassified
and
Transferred

00-01-10-18:00

Layoff Policies for Staff Members

As of April 30, 2008 this policy has been reclassified and transferred. 

This policy establishes procedures that are also aligned with the provisions of the University's various bargaining agreements concerning the layoff, bumping and recall rights of staff employees (non-faculty).  Since the Department of Human Resources has the sole accountability for articulating and implementing the various provisions and associated procedures pertaining to this matter, this policy will be maintained henceforth at the Human Resources site: http://www.umdnj.edu/hrweb/policies/pl203015.pdf 

Reclassified
and
Transferred

00-01-30-50:00

Fire and Life Safety, Amended on 03/18/08

Revised with Substantive changes.

Purpose:

The purpose of this policy is to safeguard life and property at the University from the hazards of fire arising from storage, handling, or use of materials or equipment, and from conditions hazardous to life and property. This policy identifies all fire and life safety codes applicable to the University, and delineates and assigns roles and responsibilities to achieve the highest level of fire safety, property protection, and compliance within the University community.

Highlights:

1.      Added clarification of roles and responsibilities for: Department Managers and supervisors, Fire Safety Coordinators, Fire wardens and buddies, School/Unit Administrators, Office of Workplace Diversity, UMDNJ Incident Commander (IC) and Emergency Responders.

2.      Department managers and Supervisors are now required to immediately report all fire related incidents to the campus emergency numbers. The policy now requires immediate reporting of all fire incidents to the NJ State Fire Marshal’s Office by EOHSS.

3.      Public Safety will secure all areas affected by fire or smoke until released by the investigating State Fire Marshal and assist external responding agencies as appropriate.

4.      Notification of all fire incidents to the NJ State Fire Marshal’s Office e by EOH SS.

5.      Added con sequence for non-compliance.

6.      Inclusion of the new Office of Emergency Management and Occupational Health and Safety (EMOHS) as the unit to which Environmental and Occupational Health and Safety Services (EOHSS) reports.

7.      Compliance Procedures have been removed and placed in a separate document, the University’s Fire and Life Safety Compliance Guide and Standard Operating Procedures.

8.      Title Changes - SVP for Academic Affairs to Executive VP for Academic & Clinical Affairs; and SVP for Administration and Finance to SVP for Administration.

9.       Agency name change: Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to Joint Commission.

10.     Terminology change: The term ‘Physically Challenged Occupants’ (PCO) has been replaced with the term ‘People with Disabilities’ (PWD).

11.     Definitions section added to clarify the meaning of the terms used in the policy.

Review/Approval Process

EOHSS coordinated the review with all appropriate schools, units and CA departments. Approved by the Board of Trustees at its meeting on March 18, 2008.


April 2008 (month posted)    

Drug-Free Environment, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To promote a drug-free workplace and learning environment for students, residents, faculty and staff in all University owned, leased and operated facilities. This policy is intended to implement the 1988 Drug-Free Workplace Act (Public Law 100-90, Title V, Subtitle D) and the 1989 Drug-Free Schools and Communities Act Amendments (Public Law 101-226, 34 CFR Part 86).

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs
  • deleted reference to University policies on Impaired Faculty and on House Officer Impairments because they are being merged with the Employees with Impairments policy
  • specified that the Office of Academic Affairs and the Department of Human Resources have responsibility for the biennial review of the drug prevention program
  • added University standard language with regard to disciplinary measures for failure to report conviction resulting from violation of criminal drug statutes

Review/Approval Process

This policy was reviewed by the University Office of Academic Affairs the Office of Faculty Affairs and Institutional Research, Human Resources and Legal Management.


Faculty Pursuing Educational Programs, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To define the requirements for faculty members wishing to participate as students in any formal educational program leading to a degree, certification or professional specialization which conflicts with their time commitment to the University.

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs

Review/Approval Process

This policy was reviewed by the University Office of Academic Affairs and the Office of Faculty Affairs and Institutional Research.


Tuition Reimbursement for Faculty, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To set forth policy on tuition reimbursement for faculty members.

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs

Review/Approval Process

This policy was reviewed by the University Office of Academic Affairs and the Office of Faculty Affairs and Institutional Research.


Hunterdon Health Fund, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To set policy on the establishment of chairs and other projects or programs endowed by the Hunterdon Health Fund.

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs

Review/Approval Process

This policy was reviewed by the University Office of Academic Affairs.


Archives: Content and Access, Amended on 04/17/08

Revised with Non-substantive changes.

Purpose:

To identify, collect, preserve and make accessible appropriate archival records that document the history of UMDNJ and its antecedent institutions.

Highlights:

  • definitions clarified and expanded with regard to administration and location
  • content of the archives is more explicitly stated
  • policy section updated to include a more specific listing of the applicable state and federal laws relevant to access and use of the specific content of the Archives.

Review/Approval Process

This policy was reviewed by the University Office of Academic Affairs, the Office of Ethics and Compliance and by the Libraries.

Family Educational Rights and Privacy Act, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To set policy concerning the control and disclosure of education records, including admissions, academic, financial aid, health and other applicable student administrative records, in compliance with the Family Educational Rights and Privacy Act (FERPA) of 1974 and its subsequent amendments.

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs
  • revised the definition of the terms UMDNJ student and enrollment.

Review/Approval Process

This policy was reviewed by the University Office of Academic Affairs, the University Registrar and the Office of Legal Management.


Requests for University-wide and School/Program-wide Individually Identifiable Student Information, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To set the policy and procedures for requests for University-wide and School/Program-wide individually identifiable student information. This policy does not cover requests for information about an individual student; such requests are covered by University policy, Family Educational Rights and Privacy Act, 00-01-25-05:00.

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs

Review/Approval Process

This policy was reviewed by the University Office of Academic Affairs and the Office of Faculty Affairs and Institutional Research.


Student Residence and In-State Tuition, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To set policy defining New Jersey residence to qualify students for in-state tuition rates; and to establish procedures for change to New Jersey residence for students previously classified as out-of-state residents.

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs
  • switched phrases for a logical sequence on V.B.3(3) and EXHIBIT 3.C.4-5

Review/Approval Process

This policy was revised by the University Office of Academic Affairs and the University Registrar.


Military leave from Academic Programs, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To establish the University's policy regarding academic credit and tuition and fee refunds for UMDNJ students called to partial or full mobilization for state or federal active duty as a member of the National Guard or a Reserve component of the Armed Forces of the United States.

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs

Review/Approval Process

This policy was revised by the University Office of Academic Affairs and the University Registrar.


Students Participating in educational Activities Outside UMDNJ or Any of its Affiliates, Amended on 04/10/08

Revised with Non-substantive changes.

Purpose:

To establish policy for students who wish to participate in University-approved educational activities outside the University or any of its affiliates.

Highlights:

  • title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs

Review/Approval Process

This policy was reviewed by the University Office of Academic Affairs, the University Registrar, the Office of Risks and Claims Management, the Office of Legal Management, and the Director Special Projects and University Admissions Coordinator.


Policy Prohibiting Sexual and Other Types of Harassment

As of May 2, 2007 this policy is under revision.

Use the following link at the Office of Workplace Diversity website
for Interim Guidelines: http://umdnjcaprod.umdnj.edu/owd/policies/policies/Interim_Guidelines-SH_Policy1.doc

Under Review

00-01-35-25:00

University Transportation - Motor Vehicle Fleet, Amended on 02/19/08

Revised with Substantive changes.

Purpose:

To establish policy for the assignment and use of University-owned or leased vehicles in the conduct of official University business and activities

Highlights

  • Replaced the Title of Senior Vice President for Administration with Vice President for Supply Chain Management as the person responsible for compliance and implementation of this policy
  • Provide for authorized transport of the University President to and from all work locations and university related functions and activities
  • Allow the University President and/or the designated driver of the University President (when on assignment to transport the President) to utilize university-owned or leased vehicles for commuting purposes
  • Allow the Executive Director for Emergency Preparedness and the Director of Logistical Services to utilize university-owned or lease vehicles for commuting purposes only in response to impending emergent or catastrophic events and/or recovery from said events
  • Mandate that all UMDNJ vehicles are required to display the appropriate vehicle decals for identification purposes, promote safe driving techniques and enhance the personal safety of UMDNJ employees and the general public

Review/Approval Process

Approved by the Board of Trustees at its meeting on February 19, 2008.


Student Essential Functions, Adopted on 03/18/08

New.

Purpose:

To establish the procedures concerning Essential Functions for student participation in educational programs at the Schools of UMDNJ.

Highlights:

1.   Enacts a policy reflecting the establishment by each School of Essential Functions that are required for a student to participate in any School, program or courses.

2.   Establishes procedures to require a student to obtain an evaluation of the student's ability to fulfill the Essential Functions.

3.   Establishes procedures to be implemented if a student cannot fulfill the Essential Functions, with or without reasonable accommodations.

Review/Approval Process:

Recommended Dr. Karen Putterman, Vice President for Academic Affairs; drafted by Ms. Freda Zackin, Associate Dean for Academic and Student Services at UMDNJ-School of Health Related Professions; reviewed and approved by the Student Affairs Deans at all Schools, the University Registrar, the Office of Legal Management, the Office of Ethics and Compliance, the University Office of Academic Affairs; and approved by the UMDNJ Board of Trustees at its meeting on March 18, 2008.


March 2008 (month posted)    

Reporting Compliance and Ethics Concerns, Amended on 01/28/08

Revised with Substantive changes.

Purpose:

The University of Medicine and Dentistry of New Jersey (UMDNJ) is committed to the prevention and detection of any fraud, waste, and abuse within the University related to all health care programs, including Federal and State healthcare programs; to the highest possible standards of ethical and legal business conduct; and to the proposition that employees should be free to express concerns to management or to report wrongful conduct without fear of reprisal. It is the responsibility of all trustees, officers, and employees of UMDNJ to report actual or suspected wrongful conduct, in good faith. Such reports shall be accepted willingly; kept confidential, to the extent possible, in conformance with applicable laws, regulations and other procedures; and addressed promptly and appropriately. Consistent with UMDNJ’s commitment, this policy formalizes and enhances existing procedures for reporting allegations of misconduct and ensures that UMDNJ is in compliance with the false claims provisions of the Federal Deficit Reduction Act.

Highlights:

  • Encourages agents/contractors to perform within the anti-fraud and false claims laws applicable to Federal and New Jersey State. Submission of false claims by any agent will result in prosecution and fines.
  • Provides an open line of communication for employees to report UMDNJ policy violation
  • Protects whistleblowers or anonymous sources who, in good faith, report wrongful conduct, from retaliation
  • Ensures that the NJ Insurance Fraud Prevention Act is made available to all concerned as it is unlawful to submit false insurance claims and to fail to disclose the occurrences of events.
  • Requires reports to be investigated by the appropriate authority.
  • Gives responsibility for the Dean, VP, President/CEOs of Healthcare units and UMDNJ Hospital Medical Director to ensure unit heads acquire the knowledge and ability to provide an ethical work environment for all staff.
  • Designates the DRC (Disciplinary Review Committee) to conduct weekly meetings to review serious disciplinary conduct or violation
  • Guarantees the OEC (Office of Ethics and Compliance) the need to disseminate relevant information in handbooks and the website, including training that will enable employees as well as new hires to be in compliance
  • Provides information for employees to familiarize themselves with the role of the Purchasing Dept.

Review and approval process

Approved by the Ethics and Compliance Oversight Committee (which is made up of the Senior Management team including the members of the President's Cabinet) on July 7, 2007.


Voluntary Furloughs, Amended on 03/03/08

Revised with Non-substantive Changes.

Purpose:

Sets policy to govern when the University may allow certain regular full or part-time staff employees (non-faculty) to request an unpaid, voluntary furlough.

Highlights: 

  • Minor language structure and grammatical corrections were made.
  • Removal of Reference to Ethics policies: Code of Ethics & Outside Activities
  • Reformatting of form: Request for Unpaid Voluntary Furlough

Review/Approval Process:

This policy was circulated to all schools, units and CA departments for review/comment, including the Office of Ethics & Compliance and Legal Management. The revision was completed by the Department of Human Resources.

February 2008 (month posted)    

Standards for Privacy of Individually Identifiable Health Information, Amended on 02/12/08

Revised with Substantive Changes.

Purpose:

To establish a policy to ensure UMDNJ’s compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and to establish standards for Privacy of Individually Identifiable Health Information.

Highlights: 

  • Gives the University’s Senior Compliance Officer – Privacy & Security, on behalf of the Vice President/Chief Ethics & Compliance Officer, oversight responsibility for the Privacy Program.
  • Designates the Unit Compliance Officers as the unit’s Privacy Liaison, specifying their program responsibilities.
  • Requires the appointment of a Unit Custodian of Medical Records, specifying their program responsibilities.

Review/Approval Process:

Approved by the Ethics & Compliance Oversight Committee (which is made up of the Senior Management team including the members of the President’s Cabinet) on July 7, 2007.


Community Event Sponsorship

As of February 12, 2008 this policy has been removed from the web while undergoing revisions.

For any related questions, please contact: The Office of University Affairs 973-972-4546.

Under Review

00-01-65-10:00

January 2008 (month posted)    

Student Rights, Responsibilities and Disciplinary Procedures, Amended on 01/10/08

The policy sets University requirements for student disciplinary procedures at the Schools.

Revised with Non-substantive changes:

  • updated references list to include a current University policy and two new University policies;
  • made appropriate reference in the body of the policy of the policies added to the references list;
  • revised the definition of the terms probation and suspension;
  • included in the confidentiality statement that communications with student’s next of kin, certain University/School officials, healthcare providers or law enforcement officers is permissible under the law under appropriate circumstances.

This revision was made in consultation with the Student Affairs Deans at all Schools, the University Registrar, the Office of Legal Management, the Office of Ethics and Compliance and the University Office of Academic Affairs.

Management of Potential Occupational/Educational Exposures to HIV, HBV and HCV, Amended on 12/18/07

The policy outlines the procedure under which postexposure prophylaxis will be made available to the University’s health-care personnel, including students, housestaff, faculty, staff and postdoctoral appointees who in the course of their studies and/or occupational activities are exposed to blood, tissue or other body or laboratory fluids that may contain human immunodeficiency virus (HIV), hepatitis B virus (HBV) and/or hepatitis C virus (HCV).

Revised with Non-substantive Changes:

  • Title change from Senior Vice President for Academic Affairs to Executive Vice President for Academic and Clinical Affairs;
  • Added the Director of EOHSS to the list of individuals responsible for implementing the policy;
  • Updated references list to include current CDC guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis ;
  • Included roles of the Office of Risk and Claims Management and of EOHSS;
  • Elaborated upon the required completion of an incident report to the Office of Risk & Claims Management and an exposure report to EOHSS.

This revision was made in consultation with the Directors of Student Health Service and the Directors of Occupational Medicine Service on all Campuses, the Office of Risk and Claims Management, the Director of EOHSS, the Office of Legal Management and the University Office of Academic Affairs.