Policies

General Administration

• 050-10: UCSF Administrative Organizational Charts

  UCSF campus organizational chart

• 050-11: Personal Use of University Property

  Differentiates between appropriate and inappropriate use of University property.

• 050-18: Subpoena

  Acceptance of legal notices such as claims, summons and complaints, or subpoenas.

• 050-19: Records Management and Retention

  Guidelines for the creation, organization, maintenance, use, retrieval, and disposition of University records.

• 050-20: University Archives

  The administration of University Archives.

• 050-21: Access to University Records

  Responsibilities under the California Public Records Act and California Information Practices Act for responding to requests for access to UCSF documents.

• 050-22: Display of Flags

  Protocol for display of national and state flags at multiple campus locations.

• 050-23: Police Department

  Outlines scope of powers, service areas, and organization of UCSF Police Department.

Academic Administration

• 100-10: Affiliation Agreements

  Guidelines and responsibilities for entering into affiliation agreements between UCSF and other institutions or hospitals.

• 100-11: Health Sciences Compensation Plan

  Defines the arrangement under which health sciences faculty are compensated for performing activities in connection with education, research, and patient care.

• 100-12: Library

  Clarifies the availability of UCSF library services, privileges and access to the library, and gifts made to the library.

• 100-14: Endowed Chairs and Professorships

  Establishment, disestablishment, and maintenance of endowed chairs and professorships.

• 100-15: International Students and Scholars

  Responsibilities of the International Students and Scholars Office (ISSO) and campus units with regard to sponsoring international students and scholars for study, employment, research, clinical service, and visits of any duration.

• 100-30: Continuing Education Programs

  Guidelines for the administration of continuing education programs offered by academic departments.

• 100-31: VAMC, Intergovernmental Personnel Act Assignment Agreements (IPAs)

  Requirements for Intergovernmental Personnel Act Assignment Agreements under which academic appointees are temporarily assigned to Veterans Affairs Medical Centers.

• 100-32: Agreements with Outside Agencies for Faculty Assignments

  Requirements for Intergovernmental Personnel Act Assignment Agreements (IPAs) or other agreements with outside agencies (does not apply to IPAs with VA Medical Centers) under which academic appointees are temporarily assigned to locations other than UCSF.

Academic & Staff Personnel

• 150-10: Conflict of Interest

  Designated employees are required to file statements of economic interests. All employees must disqualify themselves from participating in a University decision when a financial conflict of interest is present.

• 150-11: Substance Abuse in the Workplace

  UCSF program to prevent illegal drug and alcohol use by employees and students, and its annual notification of each employee and student of the program.

• 150-12: Affirmative Action/Nondiscrimination in Employment

  Regarding equal employment opportunities to all individuals and affirmative action for qualified members of groups underrepresented in the workforce.

• 150-13: Sexual Harassment and Sexual Violence

  Responsibility of UCSF to prevent, correct, and, when necessary, discipline behavior to create and maintain a community in which all individuals can work together in an atmosphere free of all forms of harassment, exploitation, or intimidation, including sexual harassment and sexual violence.

• 150-15: Reporting of Employee Deaths

  Deaths of UCSF personnel must be reported to the appropriate offices.

• 150-17: Identification Cards

  Ensures the distribution and use of photo identification cards for all University employees and students.

• 150-18: Critical Position Background Checks

  Employees and/or applicants for certain positions designated as "critical" must undergo background checks.

• 150-19: Nondiscrimination Regarding Language Spoken in Workplace

  Employees are free to speak languages other than English in the workplace.

• 150-21: Registered Campus Organizations

  Guidelines for the formation of campus organizations and eligibility for membership.

• 150-22: DMV Employer Pull Notice Program Participation

  The circumstances that require a UCSF employee to enroll in the California Department of Motor Vehicles (DMV) Employer Pull Notice program and actions the University may take if the University is notified of any disqualifying action reported by the DMV.

• 150-24: Workers' Compensation

  Directs and outlines the responsibilities for UCSF employees; supervisors; UCSF Disability Management Services; and UCSF Workers’ Compensation should a work-related injury or illness arise within the course and/or scope of employment.

• 150-25: UCSF Fitness & Recreation Centers

  Establishes eligibility for membership at UCSF Fitness & Recreation Centers.

• 150-26: Employee Disability/Reasonable Accommodation

  Ensure nondiscrimination in the selection, employment, and advancement practices of applicants and employees with disabilities in compliance with federal and state regulations.

• 150-27: Violence and Bullying

  UCSF commitment to a safe environment that is free from bullying, intimidation, threats, and/or acts of violence.

• 150-28: Americans with Disabilities Act (ADA) Barrier Removal

  Establishes the decision-making authority and financial responsibilities at UCSF for Programmatic and Physical Barrier Removals and Accommodations required under the federal Americans with Disabilities Act (ADA) and the California State Fair Employment and Housing Act (FEHA).

• 150-30: UCSF Industry Relations Policy

  Responsibilities regarding interactions between the University community and industry relating to educational, clinical, and research activities. 

Business Administration

• 200-15: Mail Services

  Delineates guidelines for the use of centralized campus mail services.

• 200-16: Notaries Public

  How employees may obtain notary public appointments and outlines the policies that appointees must observe in the execution of these duties.

• 200-17: Parking

  Basic rules governing parking and the use and allocation of parking permits.

• 200-19: Large Equipment

  Rules governing the receipt of goods (including equipment, furniture, and supplies) for official University business, inspection for damage, and delivery to the ordering departments.

• 200-20: Reprographics and Quick Copy

  Use of internal printing and copying services and administration of charges for these services.

• 200-23: Storage of University Property

  Use of storage space available to campus departments through Logistics.

• 200-24: Gas & Ethanol Sales

  Rules governing the purchase of gas and ethanol from Logistics for conducting University business.

• 200-25: Capital Asset Surplus

  Rules governing the disposal of capital asset surplus equipment.

• 200-26: Transportation

  Use of and access to campus transportation assets.

• 200-27: Use of University Vehicles

  Rules governing the use of University of California San Francisco owned and leased vehicles.

• 200-28: HIPAA Business Associates

  Documents UCSF's obligation to ensure that Business Associates, agents, and subcontractors comply with privacy and security laws and regulations and to take remedial action regarding any breach of duty by a Business Associate.

• 200-29: Identity Theft Prevention and Response Policy

  Ensure compliance with federal laws pertaining to Identity Theft and to set forth guidelines for establishing the UCSF Identity Theft Prevention and Response Programs.

• 200-31: Alcohol Policy

  Ensure prudent and safe use of alcoholic beverages and to promote responsible behavior regarding the service and consumption of alcoholic beverages.

• 200-32: Workforce Sanctions for Patient Privacy Violations

  Describes sanctions taken by UCSF when workforce members fail to comply with our patient privacy and confidentiality policies and procedures. 

Communications

• 250-13: Use of University Name, Seal, Logo and Brand Identity

  Use of the University name, seal, UCSF logo, and adherence to the UCSF brand identity.

• 250-14: Press and Media Relations

  A single administrative department is delegated authority to coordinate, maximize, and facilitate all interactions with press, other news media, and commercial entities.

• 250-15: Publications

  Campus standards for consistent quality and content of all publications intended to promote or explain the programs or activities of UCSF.

• 250-16: Letterhead Stationery

  Graphic standards for UCSF letterhead stationery and business cards and guidelines for their appropriate use.

Financial Administration

• 300-11: Accounts Receivable

  Managing accounts receivable including granting of credit, invoicing, recording and reconciling the transaction in the financial records, collection efforts, and write-offs of delinquent accounts.

• 300-12: Agency Funds

  The establishment and administration of agency funds when UCSF may act as a fiscal agent for outside agencies such as student, faculty, staff, governmental, or private organizations or activities. 

• 300-14: Cashiering

  Ensuring compliance with minimum requirements for handling and processing cash and cash equivalents to safeguard these assets, ensure accurate processing, and proper reporting.

• 300-19: Expenditures of Sponsored Projects

  Responsibilities of principal investigators to incur expenditures in accordance with applicable guidelines.

• 300-23: Contributions and Donations

  Conditions under which financial or material contributions and donations may be made by the University, and approval authorization. 

• 300-29: Honoraria

  Circumstances in which payment of honoraria is appropriate and defines eligibility for payment.

• 300-31: Payroll

  Ensure that departments meet federal and state regulatory standards and UCSF is in compliance with applicable labor requirements for the timely completion of new hire documentation.

• 300-35: Campus Short Term Investment Pool (STIP) Distribution

  Distribution of Short Term Investment Pool (STIP) earnings at the UCSF campus.

• 300-40: Academic Senate Funded Travel

  Eligibility requirements and purpose of travel grants awarded by the Academic Senate.

• 300-41: Advance Payments for Vendors

  On making advance payments to vendors and the proper documentation needed in order to protect the financial interests of UCSF.

• 300-42: Financial Systems Access for Affiliates

  Defines UCSF “affiliates” and “financial systems” and establishes rules and procedures for affiliate access to financial systems.

• 300-43: Travel & Meeting/Entertainment

  UCSF-specific policies relating to the areas of travel, meeting, and entertainment that are not covered by UC Office of the President policies.

• 300-44: Petty Cash and Change Funds

  Outlines the requirements and responsibilities regarding the establishment, use, replenishment, custodian transfer, termination, and physical security of petty cash and change funds.

• 300-45: Fiscal Close

  Provides an overview of the University’s fiscal month-end and fiscal year-end financial closing process.

• 300-46: General Ledger Verification

  Governs verification of general ledger (GL) transactions, which is essential for an effective internal control environment.

• 300-47: Faculty Recruitment Allowance Program Repayment

  Sets forth the repayment provision for faculty receiving a payment under the Faculty Recruitment Allowance Program (FRAP) as part of their recruitment.

• 300-48: Sales & Service Center(s) Recharges, External Sales & Services of Education Related Activities, & Common Cost Allocations

  Establishes a mechanism for defining, establishing, and closing sales and service center activities and for developing, requesting, and implementing the rates for these activities.

• 300-49: Deficit Monitoring and Resolution

  Outlines responsibilities for monitoring deficits and identifies types of corrective action administrative officials should take to resolve deficits.

Audit and Advisory Services

• 350-11: External Audits and Agency Reviews

  Outlines the scope, responsibilities and procedures that will be employed in coordinating and managing external agency audit and investigation activities at UCSF.

• 350-12: Internal Controls

  Outlines the objectives and principles of campus internal controls.

Research

• 400-10: Academic, Legal and Financial Policies of Contracts and Grants

  Ensures appropriate scientific and financial management of research, training, and other extramurally funded projects.

• 400-11: Eligibility to Submit Proposals for Extramural Funds (PI Status)

  Outlines eligibility to submit proposals for extramural funds.

• 400-12: Contract and Grant Solicitation and Acceptance or Execution

  Defines the authority to solicit and accept or execute contracts or grants for instruction or research.

• 400-16: Award Acceptance and Execution of Contracts and Grants

  Defines responsibilities for the review, acceptance, and execution of contracts and grants.

• 400-19: Research Involving Human Subjects

  Mandates compliance with all federal regulations, state laws, and University of California policies governing the use of human subjects in research.

• 400-20: Research and Instruction Using Animal Subjects

  Ensures institutional compliance with all applicable federal and state laws and regulations and University policies governing the use of animals in research.

• 400-21: Housing of Animals for Research

  Mandates that all animals used for research at UCSF must be housed in designated animal care facilities in order to comply with federal regulations.

• 400-22: Clinical Trials Registration & Reporting

  Establishes UCSF standards for Clinical Trial registration to comply with Food and Drug Administration requirements and to secure the ability to publish clinical trial results under the International Committee of Medical Journal Editors standards.

• 400-23: Patents

  Establish the rights of the various parties interested in potentially patentable inventions.

• 400-24: Integrity of Research

  Research at UCSF must be conducted in a manner appropriate to its academic goals to protect and maintain the integrity of research and of the institution.

• 400-25: OnCore Utilization and APeX Billing Review for Clinical Trials

  Requirements to track research study participants and events in OnCore and APeX; expectations for compliance with internal control standards to ensure integrity of billing procedures for clinical trials.

Gifts & University Support

• 450-10: Authority to Solicit Gifts and Private Grants

  Establishes authority to solicit funds through gifts, private grants and events.

• 450-11: Gift Acceptance and Acknowledgement

  Establishes authority to accept and acknowledge gifts and private grants.

• 450-12: Reporting of Gifts and Private Grants

  Outlines the criteria used in determining gift or private grant status and relevant reporting requirements.

• 450-13: Fundraising Campaigns

  Establishes authority to approve and conduct fundraising campaigns.

• 450-14: Levels of Endowments (under revision)

  This policy is under revision.

• 450-15: Acceptance of Works of Art and Objects for Campus Beautification

  Governs acceptance of, liability for, and placement of campus art, non-art gifts intended for campus beautification, and memorials.

• 450-16: Fundraising Events

  Ensures that fundraising events are consistent with campus and University of California goals and policies.

• 450-17: Allocation, Reallocation and Administration of Gifts and Bequests

  Describes how UCSF implements UCOP Administrative Guidelines for Allocation, Reallocation and Administration of Gifts and Bequests Received.

• 450-18: Infrastructure and Operations Assessment

  Outlines the campus application of an infrastructure and operations (I&O) assessment to gifts and endowment income to provide a portion of the financial support needed to fund campus infrastructure and core administrative services. 

• 450-19: University Support Groups

  Sets forth to enlist volunteer leadership of support groups in UCSF's implementation and stewardship of activities conducted in its name. 

• 450-20: UCSF Foundation

  Describes the UCSF Foundation, which supports UCSF’s core mission of advancing health worldwide by raising money for the University, and its relationship to UCSF.

Community and Government Relations

• 500-12: Communication with Government Officials and Agencies

  Ensures consistent, accurate, and timely communication with government officials and agencies.

• 500-13: Communication with Community Organizations

  Ensures the development of positive relations with community organizations and ensures that campus resources are effectively shared with the community.

Health & Safety

• 550-10: Smoke-Free Workplace

  Provides for a smoke-free campus policy to minimize health risk, improve the quality of air, and enhance the environment in all facilities.

• 550-12: Environmental Health and Safety Purchasing Standards

  Ensures that certain types of equipment meet minimum Occupational Safety and Health Administration (OSHA) and other regulatory standards.

• 550-17: Employee Health Services

  Delineates services provided by the Employee Health Service to comply with this mission.

• 550-19: Service and Assistance Animals

  Provides guidance with respect to presence of animals at UCSF.

• 550-20: UCSF Communicable Disease Surveillance and Vaccination Policy

  Identifies requirements for UCSF-wide surveillance and vaccinations to reduce the risk of exposure and transmission of communicable diseases at UCSF locations. 

• 550-21: UCSF Campus Communicable Disease Exposure Follow-up

  Assigns actions and responsibilities required for confirming a UCSF campus exposure to a communicable disease.

• 550-22: Tobacco-Free at Work

  Provides for a tobacco-free at work policy to minimize health risks, improve air quality, and enhance the environment at UCSF locations including the surrounding community.

• 550-23: Emergency Management

  Delineates campus, departmental, student, staff, and faculty responsibilities to ensure emergency preparedness and responsiveness.

• 550-24: Chemical Safety

  Establishes requirements and responsibilities for the safe use of hazardous chemicals in all facilities at UCSF. 

• 550-25: Drone Operations

  Promotes safe operations of drones and model aircraft while meeting the University’s regulatory compliance and reporting requirements.

• 550-26: Workplace Safety and Environmental Protection

  Delineates responsibilities for all UCSF employees, students, visitors, volunteers, and contractors to work safely, and to identify and correct hazards in the workplace.

• 550-27: Radioactive Drug Research

  Ensures necessary radiological and pharmacological safety for subjects who participate in certain research protocols using radioactive substances.

• 550-28: Radiation Safety

  Describes UCSF Radiation Safety Committee and responsibilities for the use of any and all sources of ionizing radiation at UCSF facilities.

• 550-29: Biosafety

  Ensures the safe conduct of research using infectious agents, select agents, and recombinant DNA technology.

Physical Facilities

• 600-12: Energy Conservation

  Ensures compliance with the provisions of the UC Policy on Sustainable Practices.

• 600-13: Key/Badge Control

  Designates central control point for UCSF badges, keys, and locks used to secure equipment or doors of UCSF locations.

• 600-16: Reservation of Classroom Space

  Centralizes the scheduling of courses and use of instructional space on campus through the Registrar.

• 600-17: Reservation of Conference and Meeting Space

  Delineates requirements for use of UCSF facilities available to provide UCSF community members and eligible non-University groups conference space.

• 600-18: Building Maintenance

  Outlines responsibilities for maintenance services on campus and delineates personnel authorized to perform work on UCSF-occupied space.

• 600-20: Signs

  Establishes guidelines for the creation, installation, and maintenance of all campus interior and exterior signs and signage programs.

• 600-21: Naming of University Properties, Programs and Facilities

  Ensures that all naming in recognition of an honoree is consistent with the University's role as a public trust.

• 600-22: Access to Building Mechanical Rooms and Electrical Vaults

  Delineates authorization for access to critical building control points for the systems that regulate power and other utilities for the campus.

• 600-23: Utilities

  Designates Facilities Services as the office responsible for providing all utilities except telephone services and data line connections.

• 600-24: Space

  Ensures that space is allocated, used, and managed, with a view toward promoting UCSF's mission, overall vision and strategic goals.

• 600-25: Video Systems Control

  Regulates the UCSF Video System, intended to deter crime and enhance the overall safety and security of UCSF locations.

• 600-26: Use of Campus Public Spaces and Special Use Areas

  Provides criteria for the use of campus open space and special use areas by eligible organizations.

• 600-27: Expressive Activities Held on UCSF Property

  Requires that the exercise of free and open expression on University Property is conducted compliant with First Amendment rights, with orderly and civil behavior that ensures public safety and does not disrupt University operations, patient care, or damage UCSF Property.

Information Technology

• 650-10: Identity and Location Management System

  Establishes the requirement to maintain a system of record for identity and location data for all UCSF employees, learners, and affiliates. 

• 650-12: Campus Cabling

  Delineates the approvals that are needed for remodeling and new construction projects requiring communications cabling or conduit.

• 650-13: Single Protocol Network Backbone

  Required protocol for traffic being routed over the backbone network.

• 650-14: Network Gateway Policy

  Prohibits network activities undertaken within a UCSF unit that may result in security risks or inappropriate use of the campus network and online resources.

• 650-15: Population Definition

  Defines the populations included in the University of California San Francisco (UCSF) infrastructure for identity management. 

• 650-16: Information Security and Confidentiality

  Provides for compliance with federal and state law, regulations, and UC policy governing security and confidentiality of Institutional Information.

• 650-17: Multicasting for Distribution of Video/Audio via the UCSF Intranet, Commodity Internet and Internet2

  Addresses the need for a minimum standard to enable multicasting on the UCSF enterprise network. 

• 650-18: Authorized and Acceptable Use of Institutional Information and IT Resources

  Defines the scope of authorized and acceptable use of UCSF Institutional Information and IT resources.

• 650-19: UCSF Network Security Monitoring

  Describes the monitoring, logging, and retention of network traffic at UCSF.

• 650-20: External Sharing of Personally Identifiable Information (PII) and PII-Derived Data

  Governance in regard to sharing UCSF-owned Personally Identifiable Information (PII) and PII-Derived Data with entities external to UCSF.

Ethics & Compliance

• 700-13: Privacy Investigation Policy

  Defines the authority and responsibility for UCSF response in relation to a potential or actual privacy breach of PHI.

• 700-14: Disclosure of Financial Interests & Management of Conflicts of Interests, Research Awards

  Requirements delineated are intended to identify and manage or eliminate conflicts of interest to promote objectivity in research design, conduct, and reporting.  

• Interim 700-15 Access Related Barrier Removal

  Reflects authority, financial responsibilities, including escalation, and contacts and brings UCSF into compliance with requirements under the federal Americans with Disabilities Act and California State Fair Employment and Housing Act (FEHA).

• Interim 150-31 Attendance Monitoring

  This policy provides a framework to manage employee attendance.

• Interim 300-50 Timekeeping

  Establish clear process and expectations for accurately recording, reviewing, and approving work hours and time off according to applicable laws and University of California policies.