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Current Status: Active PolicyStat ID: 4484818

University Procedure for Policy Management



To provide specific steps for University units to follow in order to create, review, revise, publish, and decommission official University Policy, Procedure, or Standards for which they are responsible, as well as guidance for the management of Unit Policies.

Scope of Applicability

This Procedure applies to all units of the University of North Carolina at Chapel Hill.


Policy Liaison

If notified by the University Policy Officer that a unit requires a Policy Liaison, the University Unit Head must appoint an individual from the unit and provide contact information for that individual to the Policy Office. When a Policy Liaison leaves the University, the unit head should select a replacement and notify the Policy Office of the change.

Approval Procedures for Creation or Material Revision

University Policy

Unless an approved exception exists, new or materially substantively-revised University Policies shall be issued according to the following process:

The Policy Liaison for an authoring unit:

  1. Develops or revises a Policy following internal Unit practices, using then-current University Policy templates;
  2. Submits the draft Policy for review by appropriate entities including subject-matter experts in other units as necessary;
  3. Submits the draft (along with any supporting information required for review) for distribution to the Policy Review Committee (PRC).

The University Policy Office shall perform any needed administrative activities and distribute the draft to the PRC, with instructions for providing feedback to the administrative unit and to the Policy Office, allowing a minimum of two weeks for review.

The issuing unit may publish the draft for concurrent public review and feedback at the unit's discretion.

The PRC shall evaluate the draft and, if needed, provide guidance and feedback ("no change needed" is an acceptable form of feedback and no response will be counted as tacit concurrence) as directed. Feedback should reflect consideration of any overlapping existing Policies, operational challenges presented, related risks, factual errors, conflict with law or regulation, ambiguity, gaps, and environmental conditions.

If the PRC determines that no additional review is necessary (the default result) then following the review period, the unit Policy Liaison should determine how or whether to incorporate feedback, perform any additional revision or review needed, and provide the draft to the unit Issuing Officer for approval.

The Policy Liaison then provides the signed version, and a publication version of the Policy to the Policy Office.

The Policy Office ensures that any changes made are consistent with feedback received and publishes the Policy, coordinating campus communications appropriately with the issuing unit.

Based on the feedback received or other considerations, an Issuing Officer may submit their proposed Policy to the EPAC for review.

If requested to do so by the issuing unit Policy Liaison, Issuing Officer, or EPAC, the Policy Office shall provide the draft, along with any background required, to the EPAC, and shall schedule a meeting with the EPAC members for review of the Policy.

EPAC may:

  1. authorize approval by the issuing Officer,
  2. request revision of the Policy,
  3. decline to review the document (which has the effect of authorizing the Issuing Officer to take independent action),
  4. Refer the Policy back to the PRC for additional consideration,
  5. Request a presentation or meeting with the Issuing Officer or others,
  6. or, in rare circumstances, may refer the Policy for consideration by the full Cabinet.

The Policy Officer shall provide guidance to the issuing unit based upon the circumstances. If recommended for Cabinet review by the EPAC, or for other reasons, the Issuing Officer may submit a policy to the Cabinet for approval.

If submitted to the Cabinet, the policy may not be approved until the Cabinet has taken action or the submission is withdrawn. If the Policy is referred to the Cabinet, the Policy Officer shall coordinate with the issuing unit and determine appropriate steps based upon the circumstances.

Procedures and Standards

In keeping with the University of North Carolina Policy on Policies and University of North Carolina Standard on Policies, Issuing Officers and their delegates may create Procedures or Standards within the context of their authority which apply university-wide.

Policy Liaisons should coordinate with the University Policy Office to determine, based on potential cost, operational change, or risk from compliance, whether a proposed University Policy, Procedure, or Standard warrants review by the PRC. If so, the Procedure outlined above for University Policy should be followed, although the Policy Office may opt to abbreviate or otherwise expedite review as needed. If only nominal risk/change/cost is anticipated, the Policy Liaison should follow internal Unit Procedures for communication of changes to Procedures or Standards and provide copies of approved documents to the Policy Office.

Unit Policy, Procedure, or Standard

Policy Liaisons may consult with the University Policy Office, request courtesy review from other Liaisons, or request full review of Unit document drafts in order to improve quality, consistency, efficiency, or coordination.


University Policy

The Issuing Officer should submit a memo to the University Policy Officer outlining the reason for decommissioning.  The Policy Office shall forward the memo for review by the PRC, and (as appropriate) EPRC to ensure that any related legal and regulatory requirements are met by other means, and to provide notice to address references in other Policies, Procedures, Standards, help documents, training materials, etc. Absent objection to the decommissioning, the Policy Officer shall schedule an official removal date, and provide a placeholder with any relevant links or other information for a duration sufficient to permit remediation of referring content and avoid user confusion.

University Procedure or Standard

The issuing Officer should submit a memo to the University Policy Officer notifying them of the change and providing a description of the reason for decommissioning. The Policy Officer shall have the document removed from publication, providing a placeholder with appropriate information to reduce confusion for a duration deemed appropriate, and ensure that records retention requirements are met.

Procedural Notes

The University Policy Office should manage review and approval for efficiency.  Wherever possible, processes should have scheduled termination dates and predictable schedules. Policy Liaisons should coordinate with the Policy Office to ensure that publication of drafts can occur in a timely and orderly way, by providing advance information about documents to be modified. The Policy Office may employ a "first-come, first-served" process or any appropriate prioritization to stagger reviews in order to avoid burdening reviewers. Reviews should be framed to assume that no response is an indication of concurrence, as the expectation is that drafts will be well-constructed and reviewed by subject-matter experts before entering an official review process. In many cases, no change will be needed and no feedback will result.


Please refer to the University of North Carolina at Chapel Hill Policy on Policies for definitions.

Related Requirements

University Policies, Standards, and Procedures

University of North Carolina at Chapel Hill Policy on Policies

University of North Carolina at Chapel Hill Standard on Policies

Contact Information

Policy Contact

University Office of Ethics Education and Policy Management
134 E. Franklin Street, Campus Box 4110, Suite 110, Chapel Hill, NC 27599
Phone: 919-445-8364
Email: ethicsandintegrity@unc.edu
Web: https://ethicsandintegrity.unc.edu/

Important Dates

Approved by:
Kim Strom-Gottfried, PhD January 07, 2017
Director, Office of Ethics Education and Policy Management

All revision dates: 1/7/2017