1000 Development, Revision, and Posting of University Policies, Procedures, and Forms
This policy defines and governs the process for creating, revising, and approving University-wide policies, procedures, and forms.
This policy does not apply to academic policies or policies that apply solely to a particular department or school.
Policies, procedures, and forms help achieve the University’s mission by establishing a strong internal control environment to support Yale’s obligations as a not-for-profit institution. These policies, procedures, and forms work to promote the efficient and effective use and stewardship of the University’s resources and minimize the risk of non-compliance with relevant laws and regulations. This policy provides standards regarding the approval, distribution, and maintenance of University policies, procedures, and forms.
Reason for the Policy
This policy exists to ensure that the University formally approves, issues, and maintains in a cohesive, user-friendly, and consistent format, official University policies and their related documents. Individuals and units engaged in developing and maintaining University policies, procedures, and forms must follow the requirements outlined in this policy for drafting, approving, revising, and withdrawing such documents.
Forms are created to provide an easy and uniform way for University employees to enter, submit, document, and utilize information specific to a business process and in support of a University policy. Forms should allow the user to enter information, electronically, directly into the form.
A brief, confidential document that proposes a new University policy or major revisions to an existing University policy. The document describes the background, justification, and likely impact of the new or revised University policy. It is presented by the Policy Sponsor (as described below), or their designee, to a meeting of the Policy Review Committee (PRC) (as described below).
Procedures describe the steps necessary to implement a University policy (the “how to”). Procedures generally indicate those who are, by role or position, responsible for the steps.
University policies are clear and concise statements of how the University intends to conduct its activities. University policies provide a set of guiding principles adopted by the University to inform decision-making and facilitate achievement of its long-term goals.
Yale University Policies and Procedures website
The Policy website houses University policies, procedures, and forms. It serves as the central repository.
Every new University policy, or major revision to an existing University policy, begins with a policy proposal. The policy proposal is prepared by the Policy Sponsor, or their designee, contains all of the pertinent information described in Procedure 1000 PR.01 Creating and Revising University Policies, Procedures, and Forms, and is presented to the PRC for review, comment, and approval.
Policy proposals are not required for minor revisions to existing University policies. Minor revisions include clarifications, non-substantive changes, and updates to reflect, for example, new position titles, new contact information, or new website addresses.
Once the PRC approves the policy proposal, if such approval is required pursuant to Section 1000.1, the Policy Sponsor is responsible for ensuring that the policy is drafted in consultation with the identified stakeholders. Every University policy must contain all information required to ensure compliance with relevant laws and regulations, as well as consistency with existing University policies. During the drafting phase, the Policy Sponsor keeps the Responsible Official (or designee) apprised of progress and issues, as appropriate.
New policies and major revisions to existing policies must undergo a formal review and approval process, as detailed in Procedure 1000 PR.01 Creating and Revising University Policies, Procedures, and Forms. This process includes review by and input from the Operations Working Group (as described below), the PRC, and the Yale community. The Responsible Official must approve the final draft of a policy.
Formal review and approval is not required for minor revisions to existing University policies.
All approved University policies must be included on the Policy website. PCS is responsible for posting approved policies, and PCS works with the Policy Sponsor to ensure that the University community is informed of new and revised policies.
New or revised procedures and forms are generally posted to the Policy website once the Policy Sponsor and PCS approve them. Two exceptions are:
- For new policies and major policy revisions, the associated procedures also must go through the formal review and approval detailed in Section 1000.3; or
- For new or revised procedures or forms with significant impact or changes, the Controller’s Office may decide, at its discretion, that the procedures or forms should go through the process described in Section 1000.3.
Every University policy, procedure, and form is subject to regular, periodic review. Review of the entirety of each University policy, procedure, and form will be conducted at least every five years by the Responsible Official, measured from the most recent revision date. PCS maintains a review cycle calendar and prompts the Responsible Official when review is due.
Any exceptions to this policy must be presented to and approved by the Controller’s Office.
Roles and Responsibilities
Operations Working Group
The Operations Working Group applies a practical and business-oriented perspective to the review of draft policies and major revisions to existing policies. Although the Responsible Official and Policy Sponsor are ultimately responsible for the content of a University policy, the Operations Working Group’s comments are critical to the successful implementation of a University policy and, therefore, should be carefully considered and addressed. The Operations Working Group includes representatives from the University’s business offices, as determined by the Senior Vice President for Operations and the Operations Strategy Group.
Policy and Compliance Services (PCS)
This unit in the Controller’s Office is headed by the Associate Controller for PCS and works with the Policy Sponsor to draft the policy proposal and the policy. While the Policy Sponsor is responsible for the content of a University policy, PCS is responsible for the editorial aspects of the University policy. PCS also coordinates the review, approval, and posting process for University policies, procedures, and forms. Finally, PCS maintains the Policy website and central repository for all University policies, including a history of all official revisions.
Policy Review Committee (PRC)
The PRC applies an institutional perspective to the review of policy proposals, draft policies, and major revisions to existing policies. Although the Responsible Official and Policy Sponsor are ultimately responsible for the content of a University policy, the PRC’s comments are critical to the successful implementation of a University policy and, therefore, should be carefully considered and addressed. The PRC includes representatives from the following offices: Provost, Controller, Auditing, Business Operations, Tax Department, Information Technology Services, Facilities, School of Medicine, General Counsel, Human Resources, Research Administration, Shared Services, and the Faculty of Arts and Sciences Dean’s office. The Controller or the Associate Controller for PCS chairs the PRC meetings.
The Policy Sponsor is the head of the Responsible Office and, if the University policy is associated with a process, the process owner. This person is responsible for ensuring that policies needed to support the Responsible Office’s mission to the University are created, periodically reviewed and, if necessary, updated. The Policy Sponsor is accountable for the University policy’s content and for its full and proper implementation. The Policy Sponsor must ensure, in consultation with the appropriate stakeholders, that the policy complies with all relevant laws and regulations.
The Responsible Office (or Responsible Offices, as may be the case) owns the University policy and is responsible for the process governed by or affected by the University policy. The members of the Responsible Office are involved in drafting and revising the University policy, developing and implementing appropriate training for those affected by the University policy, and ensuring compliance with the University policy.
This person is ultimately accountable and responsible for the content of, and compliance with, the University policy. The Responsible Official is kept apprised of any new or revised University policy under their purview by the relevant Policy Sponsor.
This is an individual, unit, or function identified in the policy proposal who will be affected by the policy or whose professional expertise relates to the subject of the policy (a.k.a. subject matter expert). The stakeholder is, therefore, consulted during the policy drafting stage. Business Operations is a stakeholder for all policies.