Policy Approval and Publication Process

Questions? Contact UCSF Administrative Policies

Overview

Description of the process for creating, submitting, and reviewing new Administrative Policies or policy revisions.

Roles and Responsibilities

  • Records and Information Management (RIM) – Executive Vice Chancellor and Provost Office (EVCPO)
  • Responsible Executive: The name and title of the senior official sponsoring the policy, often a vice chancellor or an associate vice chancellor.
  • Responsible Office: The office charged with administering the policy and accountable for the policy’s accuracy, interpretation, and updating.
  • Policy Owner: Subject matter expert who serves as the content owner and primary resource to the community for questions about the policy.

Process

Step1

Policy Development

The Policy Owner:

  • completes a Policy Action Form (PAF) and policy template
  • drafts proposed policy according to the template and consults with appropriate key stakeholders
  • circulates PAF for signature
  • works directly with unit coordinator and EVCPO toward completion.

Step2

Policy Initiation

Policy Owner submits:

  • draft PAF that outlines the proposed purpose and changes
  • first draft of the policy or revision
  • redline (if a policy revision) to the EVCP Records and Information Management (RIM) team
     

Step3

First RIM Review

The RIM team:

  • evaluates the draft PAF and conducts a preliminary review of the draft policy. The review ensures the policy follows UCSF guidelines and excludes procedural content.
  • assists the Policy Owner in determining the offices and stakeholders that should be informed, including, but not limited to UC Legal, Labor and Employee Relations, and Academic Senate.
  • provides feedback to the Policy Owner, who must address the comments and submit a revised draft, if necessary, and discusses next steps.
     

Step4

Approval of PAF

  • Policy Owner circulates finalized Policy Action Form for electronic signature with a clean copy and redline version (if revision) of the policy.
  • The RIM team is the final signatory on the form.
     

Step5

Notice of Proposed Change and Circulation for Comment

The RIM team:

  • sends a 45-day call for comment to the community with opportunity to provide comments via a survey. 
  • provides access to comments to the Policy Owner throughout the comment period. 
  • closes the survey at the end of the comment period and provides a final copy of the comments to the Policy Owner.
     

Step6

Post-Comment Action

The Policy Owner:

  • reviews the collected feedback and creates a final draft of the policy, incorporating any necessary changes. 
  • consults with RIM team as needed. 
  • submits the Policy Publication Form, including redline and clean versions of the policy.
     

Step7

Publication

  • Once the Policy Owner has gathered all necessary approvals via the Policy Publication Form, the RIM team will publish the policy on the UCSF Policy website.
  • For new policies, a policy number is assigned based on subject area.
  • The RIM team will send an email notification to all relevant parties once the publication is complete.