Reporting Improper Governmental Activities and Protection Against Retaliation (Whistleblower Policy & Whistleblower Protection Policy)


UCSF is committed to operating in an ethical, honest, and lawful manner. This policy establishes procedures for reporting events that do not meet these standards as well as campus procedures for implementing the California Whistleblower Protection Act (government Code sections 8547-8547.13).


Available in the University of California Policy on Reporting and Investigating Allegations of Suspected Improper Governmental Activities (Whistleblower Policy) and in the University of California Policy for Protection of Whistleblowers from Retaliation and Guidelines for Reviewing Retaliation Complaints (Whistleblower Protection Policy).

UCSF follows the University of California Policy on Reporting and Investigating Allegations of Suspected Improper Governmental Activities (Whistleblower Policy) and the University of California Policy for Protection of Whistleblowers from Retaliation and Guidelines for Reviewing Retaliation Complaints (Whistleblower Protection Policy.) This policy supplements and provides local procedures and responsibilities for implementing these policies at UCSF.

  1. Locally Designated Official (LDO)
    The Chief Ethics and Compliance Officer serves as the LDO, is responsible for oversight and maintenance of this policy, and acts as the liaison between UCSF and the Office of the President.
  2. Whistleblower Coordinator
    1. UCSF’s Whistleblower Coordinator is the Director of Audit Services.
    2. The UCSF Campus Whistleblower Coordinator is responsible for the overall coordination and implementation of this policy and procedures to ensure that UCSF effectively responds to whistleblower complaints.
    3. The Whistleblower Coordinator accepts and reviews all retaliation complaints that are associated with current or past investigations and works with the campus Investigation Group to ensure retaliation complaints are properly investigated.
    4. The Whistleblower Coordinator refers whistleblower retaliation complaints to a designated Retaliation Complaint Officer for fact-finding when a grievance process is not appropriate. In such cases, the fact finding process, reporting, and resolution will be consistent with the UC Whistleblower Protection Policy.
  3. Retaliation Complaint Officers (RCOs)
    1. With oversight and assistance from the Whistleblower Coordinator, designated Retaliation Complaint Officers (RCOs) ensure that a competent investigation is conducted on the allegation of retaliation or interference.
    2. The RCO shall work with the Whistleblower Coordinator to ensure the following:
      1. Existing grievance procedures, where applicable, allow for adequate investigation and report of RCO findings on the allegations; or
      2. Hearing officers or arbitrators, where applicable, adequately cover the allegations; or,
      3. A competent and timely fact-finding is conducted on allegations that are not appropriately handled by existing grievance process.
      4. Investigation is conducted in accordance with the Whistleblower Retaliation Policy.
    3. The designated RCOs for UCSF are:
      1. Director—Human Resources Specialty Center for staff employees on campus;
      2. Executive Director —Human Resources for staff employees at the Medical Center;
      3. Assistant Vice Provost – Academic Affairs for academic employees, including faculty;
      4. Director of Student Relations for students.
  4. Investigations Group
    1. UCSF has established an Investigations Group (“I Group”), which is consistent with the UC Whistleblower Policy, to provide coordination and oversight of investigative activities and facilitates communication among appropriate parties.
    2. The I Group membership is appointed by the Chancellor.
    3. The I Group is chaired by the LDO and includes representatives from Audit Services, Human Resources, Police, Legal Affairs, and other essential areas of the UCSF community. In addition, individuals with specialized expertise may be required to attend on an ad hoc basis for investigation of certain matters.
  5. Investigative Responsibilities
    1. While appropriate investigative processes will be determined and assigned based on the individual circumstances of an improper governmental activities report, the following general responsibilities shall apply to investigations under this policy:
      1. Internal Audit is responsible for investigating allegations of known or suspected misuse of University resources, including fraud, financial irregularities, and the financial consequences of the above. If criminal activity is detected, consultation with UC police shall determine whether the police should take the lead, participate, or initiate a separate investigation.
      2. Campus Police are responsible for investigations of known or suspected criminal acts within their jurisdiction. In cases involving principally criminal concerns, the campus police shall be the lead investigators and others with an investigative interest shall work in support of police investigation.
      3. Other Investigations—Investigations of personnel matters, scientific misconduct, clinical billing, regulatory non-compliance, student misconduct, and other matters shall be assigned by the I Group, based upon the issues raised (e.g., Human Resources). In cases involving overlapping interests among investigative bodies, assistance and cooperation will be provided between the investigators based on the relative expertise of the investigative bodies.
  6. Managers, Administrators and Employees in Supervisory Roles
    1. Managers are responsible for reporting any allegations of suspected improper governmental activity to the Whistleblower Coordinator or to the LDO—whether reported verbally or in writing, by their subordinates, or discovered in the course of performance their duties.
    2. The manager shall document oral reports by a written transcription of information communicated to him/her; internal communications regarding allegations of improper governmental activities should also normally be in writing.
    3. If managers are not certain that an issue reported or discovered is appropriate for referral or reporting, they shall consult with the Whistleblower Coordinator.
  7. Employees and Other Individuals
    1. Employees or other persons are encouraged to use the reporting procedures in this policy if they have a good faith belief that an improper governmental activity has occurred or is continuing to occur.
    2. All employees of the University have a duty to refrain from retaliation against or interference with individuals who want to report, or who have reported, an improper governmental activity.
    1. Reporting Suspected Improper Governmental Activities (IGA)--University employees or others can file a report of a suspected IGA in the following ways:
      1. completing Exhibit A and submitting it to the Whistleblower Coordinator via fax (415-752-0853); mail (Audit Director, 1855 Folsom Street, Suite 107, San Francisco, CA 94143); or email ([email protected])
      2. going online at EthicsPoint Whistleblowing Hotline (systemwide hotline)
      3. calling the UC Confidential Hotline 800-403-4744
      4. contacting the State Auditor at 800-952-5665 or at
      5. contacting the California Attorney General by calling 800-952-5225
      6. reporting--University employees also can report suspected IGAs directly to their supervisors. Reports may be made anonymously; however, anonymous reports must provide sufficient details and corroborating evidence to justify the commencement of an investigation.
    2. Reporting Whistleblower Retaliation Complaints
      1. To be covered by the retaliation provisions of the Whistleblower Protection Act, the retaliation complaint must be accompanied by a sworn statement made under penalty of perjury that its content is true or is believed to be true.
      2. Whistleblower retaliation complaints may be filed by any of the following methods
        1. under the applicable grievance or complaint resolution procedure
        2. with the Whistleblower Coordinator by completing Exhibit B and submitting it to the Whistleblower Coordinator
        3. with the employee's supervisor by completing Exhibit B and submitting to the supervisor
      3. Regardless of how the whistleblower retaliation complaint is filed, the Whistleblower Coordinator will manage the process for reviewing the complaint that will follow the procedures set forth in the UC Whistleblower Protection Policy
      4. Time limits for filing reports
        1. reports under the Whistleblower Protection Policy must be filed within 12 months of the alleged retaliation or interference
  1. California Government Code Section 8547-8547.13 Reporting of Improper Governmental Activities
  2. UC Office of the President
    1. Policy on Reporting and Investigating Allegations of Suspected Improper Governmental Activities (the “Whistleblower Policy”)
    2. Policy for Protection of Whistleblowers from Retaliation and Guidelines for Reviewing Retaliation Complaints (the “Whistleblower Protection Policy”)
    3. Business and Finance Bulletins RMP-8, Legal Requirements on Privacy of and Access to Information
  3. UC Office of the President, Personnel Policies for Staff Members:
    1. Policy 61, Release during the Probationary Period or from Limited, Casual/Restricted, and Floater Appointments
    2. Policy 62, Corrective Action--Professional and Support Staff
    3. Policy 63, Investigatory Leave
    4. Policy 64, Termination of Career Employees--Professional and Support Staff
    5. Policy 65, Termination of Career Employees--Managers and Senior Professionals, Salary Grades I through VII
    6. Policy 67, Termination of Career Employees—Managers and Senior Professionals, Salary Grades VIII and IX
    7. Policy 70, Complaint Resolution
  4. Local and Systemwide Labor Agreements (Contracts)
  5. UC Office of the President Academic Personnel Manual (APM) and Corresponding UCSF Procedures, Guidelines and Bylaws:
      1. Section 015, The Faculty Code of Conduct
      2. Section 016, University Policy on Faculty Conduct and the Administration of Discipline
        1. UCSF Interim Procedure for Investigation of Faculty Misconduct and the Administration of Discipline
      3. Section 140, Non-Senate Academic Appointees/Grievances
      4. Academic Senate Bylaw 335, and UCSF Division Bylaw 141
        1. UCSF Committee on Privilege & Tenure Grievance Guidelines & Procedures
      5. Section 035, Affirmative Action and Nondiscrimination in Employment
      6. Section 025, Conflict of Commitment and Outside Activities of Faculty Members
  6. UCSF Bylaws of the Medical Staff see
  7. Bylaws, Regulations, and Procedures of the School of Medicine, Bylaws of the Faculty of the School of Medicine (University of California, San Francisco)
  8. Bylaws, Regulations, and Procedures of the School of Nursing, Bylaws of the Faculty of the School of Nursing (University of California, San Francisco)
  9. Bylaws, Regulations, and Procedures of the School of Pharmacy, Bylaws of the Faculty of the School of Pharmacy (University of California, San Francisco)
  10. EthicsPoint Whistleblowing Hotline (systemwide hotline)
  11. Office of Ethics and Compliance, Integrity of Research Notice