Table of Contents: Institutional Handbook of Operating Procedures

The policies in this section have been vetted through the review and approval process in accordance with The University of Texas Medical Branch at Galveston’s Institutional Handbook of Operating Procedures (IHOP), established under the guidelines of The University of Texas System, Board of Regent’s Rules.
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SECTION 1     IHOP  -  Official Governance
IHOP - 01.01.01 - Institutional Mission Statement of the University of Texas Medical Branch (UTMB)
IHOP - 01.01.02 - Rules and Regulations of the Board of Regents
IHOP - 01.01.03 - Institutional Handbook of Operating Procedures
IHOP - 01.01.04 - Intellectual Property and the Office of Technology Transfer
SECTION 2     IHOP  -  General Administration
IHOP - 02.01.03 - Release of Information Under the Texas Public Information Act
IHOP - 02.01.05 - Business Continuity Planning
IHOP - 02.06.01 - Use of UTMB Facilities
IHOP - 02.06.02 - Special Use Facilities
IHOP - 02.06.03 - Naming of Buildings, Other Facilities, and Entities
IHOP - 02.06.04 - Registering a Faculty, Staff or Student Organization
IHOP - 02.06.06 - Posting of Notices on Institutional Communication Venues
IHOP - 02.06.07 - Fundraising Projects Benefiting UTMB
IHOP - 02.06.09 - Food Services Policy
IHOP - 02.06.10 - Food Services Contracting Policy
IHOP - 02.07.01 - Signage and Wayfinding Approval
IHOP - 02.07.02 - Space Management
IHOP - 02.07.05 - Temporary Signs Standards
IHOP - 02.07.06 - Art Guidelines and Procurement Policy
IHOP - 02.19.03 - Mobile Communication Devices Policy
IHOP - 02.19.04 - UTMB Web Accessibility Policy
IHOP - 02.19.06 - Information Resources Security
IHOP - 02.19.07 - Use of Social Media
IHOP - 02.19.09 - Digital Millennium Copyright Act Notice and Procedures
SECTION 3.1     IHOP  -  Employee  -  General
IHOP - 03.01.01 - Staffing During Adverse Conditions
IHOP - 03.01.02 - Employee Files
IHOP - 03.01.03 - Telecommuting (Alternate Work Site)
IHOP - 03.01.04 - Performance Management Program
IHOP - 03.01.05 - Attendance
IHOP - 03.01.06 - Personal Appearance
IHOP - 03.01.07 - Work Schedules and Work Week
IHOP - 03.01.09 - Discipline, Dismissal and Appeal for Classified Employees
IHOP - 03.01.10 - Grievance Policy
SECTION 3.2     IHOP  -  Employee  -  Regulatory Compliance
IHOP - 03.02.01 - Nondiscrimination, Equal Employment Opportunity and Affirmative Action
IHOP - 03.02.02 - Americans with Disabilities Act Policy
IHOP - 03.02.04 - Sexual Harassment and Misconduct
IHOP - 03.02.05 - Consensual Relationships Policy
IHOP - 03.02.05 - Verification of Selective Service Registration
IHOP - 03.02.06 - Criminal History Background Checks for Employment
IHOP - 03.02.07 - Eligibility and Tax Requirements
IHOP - 03.02.08 - Verification of Debarred and Suspended Individuals and Organizations
IHOP - 03.02.09 - Non-Retaliation Policy
IHOP - 03.02.10 - Use of Consumer Reports for Employees, Students and Contractors
SECTION 3.3     IHOP  -  Employee  -  Employment
IHOP - 03.03.01 - Processing Non-Citizen Employees and Students for Employment
IHOP - 03.03.02 - Faculty and Administrative & Professional Recruitment
IHOP - 03.03.03 - Classified Staff Recruitment and Transfer
IHOP - 03.03.04 - Eligibility for Re-employment Process
IHOP - 03.03.05- Dual State Employment
IHOP - 03.03.06 - Employment of Relatives (Nepotism)
IHOP - 03.03.07 - New Employee Probationary Period
IHOP - 03.03.09 - Reduction in Force (RIF)
IHOP - 03.07.12 - Employee Resignation and Exit Process
SECTION 3.4     IHOP  -  Employee  -  Compensation
IHOP - 03.04.01 - Compensation Policy for Professional and Classified Employees
IHOP - 03.04.02 - Fair Labor Standards Act Regarding Deductions from Salary of UTMB Exempt Employees
IHOP - 03.04.03 - State Compensatory Time
IHOP - 03.04.04 - Pay for On-Call Classified Employees
IHOP - 03.04.05 - Overtime
IHOP - 03.04.06 - Shift Differential
IHOP - 03.04.07 - Longevity Pay
SECTION 3.5     IHOP  -  Employee  -  Training and Development
IHOP - 03.05.01 - Tuition Reimbursement for College Credit Coursework
IHOP - 03.05.02 - New Employee Orientation
IHOP - 03.05.03 - Long-Term Training (LTT)
IHOP - 03.05.04 - Mandatory Education and Training for UTMB 's Workforce
SECTION 3.6     IHOP  -  Employee  -  Leave
IHOP - 03.06.01 - Jury Service and Witness Fees and Service
IHOP - 03.06.02 - Time Off for Voting
IHOP - 03.06.03 - Paid Military Leave
IHOP - 03.06.04 - Extended Unpaid Military Leave
IHOP - 03.06.06 - Official Holidays
IHOP - 03.06.07 - Leave of Absence Without Pay
IHOP - 03.06.08 - Parental Leave
IHOP - 03.06.09 - Family and Medical Leave
IHOP - 03.06.10 - Sick Leave
IHOP - 03.06.11 - Sick Leave Pool
IHOP - 03.06.12 - Vacation
IHOP - 03.06.13 - Assistance Dog Training Leave for Employees with a Disability
IHOP - 03.06.15 - Leave for Employees Donating an Organ, Bone Marrow, or Blood
IHOP - 03.09.03 - Emergency Leave (Including Funeral Leave)
IHOP - 03.09.12 - Leave for Employees Certified as Firefighter, Emergency Medical Service, and Disaster Service Volunteers
SECTION 3.7     IHOP  -  Employee  -  Health and Wellness
IHOP - 03.07.01 - Fitness for Duty
IHOP - 03.07.02 - Pre-Employment Drug Testing
IHOP - 03.07.03 - Employee Assistance Program (EAP)
IHOP - 03.07.04 - Temporary Job Modification
IHOP - 03.07.05 - Workers Compensation Insurance
IHOP - 03.07.06 - Tobacco Free Policy
IHOP - 03.07.07 - Vaccination of Healthcare Workers to Protect Patients from Vaccine Preventable Infections
IHOP - 03.07.08 - Worksite Breast feeding
SECTION 4     IHOP  -  Fiscal
IHOP - 04.01.04 - Time and Attendance Reporting
IHOP - 04.02.01 - Historically Underutilized Businesses (HUB)
IHOP - 04.03.01 - Travel Policy
IHOP - 04.04.02 - Official Function Expenditures
IHOP - 04.04.05 - Departmental Cost Center Financial Review and Reconciliation
IHOP - 04.04.13 - Cash Handling and Reporting
IHOP - 04.04.17 - Membership Organization Dues
IHOP - 04.04.20 - Use of State Sales Tax Exemption Form
IHOP - 04.05.01 - Service Centers
IHOP - 04.05.02 - Consistent Treatment of Costs
IHOP - 04.05.03 - Fringe Benefit Costs
IHOP - 04.05.05 - Hiring Independent Contractors
IHOP - 04.05.06 - Procurement Policy
IHOP - 04.05.07 - Cost Sharing Policy
IHOP - 04.05.08 - Effort Reporting Policy
IHOP - 04.05.09 - Cost Transfer Policy
IHOP - 04.07.04 - Accountability and Responsibility for State Property
SECTION 5     IHOP  -  Faculty
IHOP - 05.01.01 - Rights and Responsibilities of Faculty Members
IHOP - 05.01.02 - Faculty Governing Authority
IHOP - 05.01.04 - New Faculty Teaching Physician Education
IHOP - 05.03.01 - Faculty and Designated Appointments by the President
IHOP - 05.03.02 - General Policies for Academic Titles
IHOP - 05.03.03 - Named Professorships and Endowed Chairs
IHOP - 05.03.04 - Retirement and Modified Service
IHOP - 05.03.05 - Faculty Recruitment Policy
IHOP - 05.03.06 - Procedures for Appointment, Promotion, or Membership in all Schools
IHOP - 05.03.07 - Joint Appointments
IHOP - 05.03.08 - Faculty Grievance Policy
IHOP - 05.03.09 - Tenure and Reappointments
IHOP - 05.03.10 - Termination
IHOP - 05.03.12 - Faculty Development Leave
IHOP - 05.03.14 - Faculty Ombudsperson Policy
IHOP - 05.05.01 - Faculty evaluations
IHOP - 05.05.02 - Periodic Performance Evaluation of Tenured Faculty
IHOP - 05.05.05 - Administrative Component of Compensation for Academic Administrators
IHOP - 05.05.06 - Faculty Credentials and Faculty Files
IHOP - 05.05.07 - Faculty Compensation Committee
IHOP - 05.07.05 - Policy on Integrity in Research
SECTION 6.0     IHOP  -  Compliance  -  Plans
IHOP - 06.01.00 - Institutional Compliance Plan
IHOP - 06.02.40 - Privacy Compliance Plan
IHOP - 06.03.01 - Billing Compliance Plan
IHOP - 06.05.00 - Research Compliance Plan
IHOP - 06.05.07 - Export Control Compliance
IHOP - 06.06.00 - Endowment Compliance Plan
SECTION 6.1     IHOP  -  Compliance  -  General
IHOP - 06.01.12 - Government and Outside Investigations
IHOP - 06.01.03 - Appeal of a Determination by the Office of Institutional Compliance
IHOP - 06.01.04 - Significant Events Reporting
IHOP - 06.01.05 - Records and Information Management and Retention
IHOP - 06.01.10 - Self-Reporting of Overpayments
SECTION 6.2     IHOP  -  Compliance  -  Privacy
IHOP - 06.02.00 - Maintaining Patient Confidentiality through the Appropriate Use and Disclosure of PHI
IHOP - 06.02.01 - Use and Disclosure of PHI Based on Patient Authorization
IHOP - 06.02.02 - Use and Disclosure of PHI for Individual Care, Notification and Directory Information
IHOP - 06.02.03 - Use and Disclosure of PHI by Personal Representatives of Minors, Incapacitated and Deceased Individuals
IHOP - 06.02.05 - Mitigation after Improper Use or Disclosure Protected Health Information (PHI)
IHOP - 06.02.08 - Use and Disclosure of Psychotherapy Notes and Physician Process Notes
IHOP - 06.02.09 - Fax Transmittal of PHI
IHOP - 06.02.10 - Physical Protections Safeguards for Protected Health Information (PHI)
IHOP - 06.02.13 - Use and Disclosure of PHI for Limited Data Sets
IHOP - 06.02.15 - Use of Notice of Privacy Practices of PHI
IHOP - 06.02.16 - Permitted Uses and Disclosures of PHI in Special Situations
IHOP - 06.02.17 - Use & Disclosure of PHI for Marketing and Fundraising
IHOP - 06.02.24 - Removal of Protected Health Information from UTMB Facilities
IHOP - 06.02.26 - Patient Rights Related to Protected Health Information (PHI)
IHOP - 06.02.29 - De-Identification of PHI
IHOP - 06.02.30 - Use & Disclosure of PHI for Research
IHOP - 06.02.32 - Verifying Identity and Authority of Individuals Requesting Protected Health Information (PHI)
IHOP - 06.02.34 - Use and Disclosure of Social Security Numbers (SSNs)
IHOP - 06.02.35 - Business Associates with Access to PHI
IHOP - 06.02.38 - Access to Protected Health Information by External Entities
IHOP - 06.02.39 - Privacy Incident Response and Breach Notification
SECTION 6.3     IHOP  -  Compliance  -  Coding and Billing
IHOP - 06.03.00 - Clinical Billing, Documentation and Coding
IHOP - 06.03.02 - Correction of Errors Related to Federal Healthcare Program Reimbursement
SECTION 6.5     IHOP  -  Compliance  -  Conflicts of Interest and Ethics
IHOP - 06.05.01 - Research Conflicts of Interest
IHOP - 06.05.02 - Ethical Interactions with Industry
IHOP - 06.05.03 - Individual Conflicts of Interest, Conflicts of Commitment, and Outside Activities
IHOP - 06.05.04 - Institutional Conflicts of Interest
IHOP - 06.05.05 - Gifts, Honoraria, Fundraising, and Other Activities
IHOP - 06.05.06 - Code of Ethics
SECTION 7     IHOP  -  Student
IHOP - 07.01.00 - Student Health Governance Board
IHOP - 07.01.01 - Students with Disabilities
IHOP - 07.01.03 - Student Conduct and Discipline
IHOP - 07.01.04 - Student Travel Policy
IHOP - 07.01.08 - Student Release During Adverse Environmental Conditions
IHOP - 07.01.10 - Student Accident & Injury Reporting
IHOP - 07.01.11 - Student Sexual Misconduct, Sexual Harassment and Sexual Assault Policy
IHOP - 07.01.12 - Consensual Relationships
IHOP - 07.01.13 - Other Non-Academic Concerns
IHOP - 07.01.14 - Student Non-Academic Grievance Procedures
IHOP - 07.01.15 - Graduate School of Biomedical Sciences Course Content and Methodology and Grievance Process
IHOP - 07.01.16 - Graduate School of Biomedical Sciences Grading and Evaluation
IHOP - 07.01.17 - Graduate School of Biomedical Sciences Academic Dismissal Appeals
IHOP - 07.01.18 - SOM - Appeal of Examination Score, Evaluation, or Course Grade
IHOP - 07.01.19 - School of Medicine Appeal of an Academic Progress Committee Decision to Dismiss a Student
IHOP - 07.01.20 - SHP Student Appeals of Grading and Unsatisfactory Academic Performance
IHOP - 07.01.22 - SON - Academic Appeal Grading and Evaluation
IHOP - 07.01.23 - SON - Academic Dismissal Appeal Procedures
IHOP - 07.01.24 - Tax-Free Sales By Registered Student Organizations
IHOP - 07.01.25 - Student Immunization Requirements
IHOP - 07.01.27 - Student of Nursing (SON) Student Drug Testing
IHOP - 07.01.28 - School of Medicine Student Drug Testing Policy
IHOP - 07.01.29 - UTMB Student Health Insurance Policy
IHOP - 07.01.30 - Family Educational Rights and Privacy Act (FERPA)
SECTION 8     IHOP  -  Health, Safety and Security
IHOP - 08.01.01 - Policy and Guidelines on AIDS, HIV, and Hepatitis B
IHOP - 08.01.02 - Tuberculosis Surveillance Program for Healthcare Workers
IHOP - 08.01.04 - Workplace Violence
IHOP - 08.01.05 - Fire Alarm and Incident Response Policy
IHOP - 08.01.06 - Removal Disposal of Hazardous Waste
IHOP - 08.01.07 - Evaluation and Treatment of Impaired Physicians
IHOP - 08.01.09 - Manufacture, Sale, Possession, Distribution, or Use of Alcohol, Controlled Substances or Illegal Drugs
IHOP - 08.01.11 - Environmental Policy Statement
IHOP - 08.01.12 - Safety Training
IHOP - 08.01.13 - Reproductive Fertility Hazards in the Work Place
IHOP - 08.01.14 - Decorations Safety Policy
IHOP - 08.01.15 - General Requirements for Use of UTMB Vehicles
IHOP - 08.01.16 - Drug and Alcohol Testing for Department of Transportation (DOT) Regulated Employees
IHOP - 08.01.19 - Portable Heating Devices
IHOP - 08.01.20 - Open Flames Prohibited
IHOP - 08.01.22 - Public Access to Automated External Defibrillators
IHOP - 08.01.23 - Above Ceiling Work Policy for Healthcare Buildings
IHOP - 08.01.24 - General Electrical Safety
IHOP - 08.01.25 - Installation and Maintenance of Dispensers for Alcohol-based Hand Sanitizer Units
IHOP - 08.01.26 - Keying Operations and Access
IHOP - 08.02.01 - Threatening Situations
IHOP - 08.02.02 - Campus Security Reporting
IHOP - 08.02.03 - Identification Badges Smart Cards
IHOP - 08.02.04 - Possession of Weapons
IHOP - 08.02.05 - Security Management
IHOP - 08.02.06 - Hostage Policy Involving Offender Correctional Patients
IHOP - 08.02.07 - Security Associated with Offender Correctional Patients
IHOP - 08.02.08 - Active Shooter Response
IHOP - 08.03.01 - Resource Conservation Policy
SECTION 9.1     IHOP  -  Clinical  -  Admission, Discharge and Transfer
IHOP - 09.01.02 - Management of Patient Belongings
IHOP - 09.01.04 - Patient Transportation
IHOP - 09.01.08 - Inpatient Absence for Personal or Therapeutic Reasons
IHOP - 09.01.09 - Delayed Discharge of Newborns
IHOP - 09.01.12 - Interfacility Transfer of Patients from UTMB
IHOP - 09.01.14 - Patient Discharge
IHOP - 09.01.15 - Adoption from the Nurseries
IHOP - 09.01.16 - Admission of Interfacility Transfer Patients
IHOP - 09.01.21 - Examination and Treatment for Emergency Medical Conditions and Women in Labor
IHOP - 09.01.22 - Determining Hospital and Emergency Department Diversion Status
IHOP - 09.01.23 - MICU CCU Admission Criteria
IHOP - 09.01.24 - Admission Discharge Criteria for Day Surgery Unit (DSU)
IHOP - 09.01.26 - Admission Discharge Transfer Criteria to SICU
IHOP - 09.01.27 - Admission Discharge Criteria for the Chronic Home Dialysis Unit
SECTION 9.2     IHOP  -  Clinical  -  Patient Records
IHOP - 09.02.01 - Management of UTMB's Protected Health Information (PHI)
IHOP - 09.02.03 - Retiring Incomplete Records
IHOP - 09.02.06 - Medical Record Access
IHOP - 09.02.07 - Use and Disclosure of Inpatient Protected Health Information
IHOP - 09.02.08 - Medical Record Forms Management
IHOP - 09.02.09 - Delinquent Medical Record Management
IHOP - 09.02.13 - UTMB Medical Record Policy
IHOP - 09.02.14 - Medical Record Retention
IHOP - 09.02.15 - Medical Record Documentation
IHOP - 09.02.16 - Scanning Protected Health Information to Epic
IHOP - 09.02.18 - Processing Specimens Without a Medical Record
IHOP - 09.02.20 - Physician-Patient Email Communication
IHOP - 09.02.21 - Medical Record Number Assignment
SECTION 9.3     IHOP  -  Clinical  -  Patient Rights
IHOP - 09.03.01 - Resources Available for Patients with Disabilities
IHOP - 09.03.02 - Use of Photograph, Video Audio Recordings and or Televising Patients
IHOP - 09.03.03 - Telephone Consent for Treatment Procedures
IHOP - 09.03.04 - Patient Family Education
IHOP - 09.03.09 - Reporting Suspected Abuse, Neglect, and Exploitation of Children, the Elderly and or Disabled Persons
IHOP - 09.03.10 - Consent for HIV Antibody Testing and for Disclosure of Results
IHOP - 09.03.13 - Patient Rights and Responsibilities
IHOP - 09.03.16 - Refusal of Consent Treatment
IHOP - 09.03.17 - Consent - Overview and Basic Requirements
IHOP - 09.03.18 - Consent - Treatment of a Minor
IHOP - 09.03.20 - Universal Childhood and Adolescent Immunizations
IHOP - 09.03.21 - Consent for Sterilization
IHOP - 09.03.32 - Abandoned Infant (Baby Moses) Policy
IHOP - 09.03.34 - Sexual Assault Examination and Collection of Forensic Evidence for the Adult, Adolescent or Pediatric Patient
IHOP - 09.03.35 - Patient-Centered Communication
SECTION 9.7     IHOP  -  Clinical  -  Visitor Information
IHOP - 09.07.01 - Hospital and Ambulatory Services Visitation
IHOP - 09.07.02 - Vendor Visitation UTMB Clinical Enterprise
SECTION 9.8     IHOP  -  Clinical  -  Financial
IHOP - 09.08.02 - UTMB Health Charity Care and Financial Assistance Policy
SECTION 9.11     IHOP  -  Clinical  -  Personnel Issues
IHOP - 09.11.01 - Licensure Certification Registration of Healthcare Professionals
IHOP - 09.11.02 - Employee Conflict with Prescribed Patient Treatment
IHOP - 09.11.04 - Standing Delegation Orders
IHOP - 09.11.04 - Standing Delegation Orders
IHOP - 09.11.05 - Physician Orders
IHOP - 09.11.06 - Criteria for Visitors from Agencies or Non-Affiliated Educational Institutions to Visit, Observe and or Participate in Patient Care at UTMB Hospitals
SECTION 9.13     IHOP  -  Clinical  -  General Clinical Procedures and Care
IHOP - 09.13.01 - Cardiopulmonary Resuscitation (CPR)
IHOP - 09.13.02 - Governance of Provider Performed Microscopy Procedures (PPMP)
IHOP - 09.13.03 - Patient-Owned Medical Equipment Devices
IHOP - 09.13.04 - Governance of Point of Care Testing (POCT)
IHOP - 09.13.05 - Moderate Sedation (Conscious Sedation)
IHOP - 09.13.06 - Initiating and Monitoring Restraints
IHOP - 09.13.07 - Latex Allergy Sensitivity Management
IHOP - 09.13.08 - Interdisciplinary Plan of Care
IHOP - 09.13.09 - Interdisciplinary Admission Assessment and Reassessment
IHOP - 09.13.10 - Changing Patient Identifiers (Name and Unit History Number)
IHOP - 09.13.11 - Medical Device Recall, Alert, Safety Hazard Notification and Response
IHOP - 09.13.12 - Summary List for Ambulatory Patients
IHOP - 09.13.13 - Unusual Event Reporting
IHOP - 09.13.14 - Adverse Drug Events
IHOP - 09.13.15 - Serological Testing for Syphilis, Hepatitis B, and HIV During Pregnancy and Delivery
IHOP - 09.13.16 - Sentinel Events
IHOP - 09.13.17 - Breastfeeding
IHOP - 09.13.18 - Disclosure of Unanticipated Outcomes
IHOP - 09.13.19 - Patient Care Alarm Systems Maintenance, Testing, and Activation
IHOP - 09.13.20 - Family Presence during Procedures and Resuscitation
IHOP - 09.13.21 - Reporting of Devices and Supplies Involved in Patient Injury, Illness, or Death
IHOP - 09.13.22 - Handling of Malfunctioning or Defective Equipment, Devices, and Supplies
IHOP - 09.13.23 - Emergency Shut-Off of Oxygen Zone Valves in UTMB Hospitals
IHOP - 09.13.24 - Patient Identifiers
IHOP - 09.13.25 - Universal Protocol for Invasive and Surgical Procedures
IHOP - 09.13.26 - Guidelines for Safe Patient Handling and Movement
IHOP - 09.13.27 - UTMB Surgical Devices and Implants Utilization
IHOP - 09.13.28 - Surgical Counts
IHOP - 09.13.30 - Medication Reconciliation
IHOP - 09.13.31 - Activation of the Medical Surgical and Obstetrical Rapid Response Team (RRT)
IHOP - 09.13.32 - Infant Child Abduction Response Policy for Inpatient Areas
IHOP - 09.13.33 - Intraosseous Catheters
IHOP - 09.13.34 - Coordination of Resources for Transplant Patients and Living Donors
IHOP - 09.13.35 - Anticoagulation Therapy
IHOP - 09.13.37 - Tube Placement for Nutrition in Adults
IHOP - 09.13.38 - Suicide Risk Screening and Suicide Precautions for Patients
IHOP - 09.13.39 - Patient Falls Prevention Plan
IHOP - 09.13.39 - Transfusion of Blood Components, Adults and Pediatrics
IHOP - 09.13.40 - Blanket and Fluid Warmer Operating Temperatures
IHOP - 09.13.40 - Blanket and Fluid Warmer Operating Temperatures
SECTION 9.15     IHOP  -  Clinical  -  End of Life
IHOP - 09.15.01 - Disposition of Deceased Patients
IHOP - 09.15.05 - Patients Initiating Advance Directives
IHOP - 09.15.06 - Making and Documenting Treatment Decisions including Withholding or Withdrawing Life-Sustaining Treatment
IHOP - 09.15.08 - Out-of-Hospital Do Not Resuscitate (OOHDNR) Orders
IHOP - 09.15.09 - Determination of Death
IHOP - 09.15.10 - Donation after Cardiac Death
SECTION 10     IHOP  -  Academic
IHOP - 10.01.01 - Academic Program Evaluation
IHOP - 10.01.02 - New Educational Program Approval Process
IHOP - 10.01.03 - Review of Existing Degree Programs
IHOP - 10.01.04 - Enrollment Reporting Policy
IHOP - 10.01.05 - Credit Hours
IHOP - 10.01.06 - SACS-COC Substantive Change Policy
IHOP - 10.02.01 - Evaluation of Academic Administrators
SECTION 11     IHOP  -  Research
IHOP - 11.01.03 - Conduct of Clinical Research
IHOP - 11.01.04 - Photography of Research Animals
IHOP - 11.01.06 - Research Related Injury of a Subject Participating in a Clinical Investigation
IHOP - 11.02.01 - Institutional Office of Regulated Nonclinical Studies
IHOP - 11.02.02 - cGMP Manufacturing & Testing - Nonclinical
IHOP  -  Supporting Documents
CRC -Log of Procedures (Muscle Biopsy)
CRC -Privilege Delineation Form (Muscle Biopsy)
Crime Prevention and Education Programs
Definitions
Designated Operative and Invasive Procedure
Faculty CV template
Faculty or Staff Organization Registration Form
FAIR USE definition
Guidelines for Registered Faculty or Staff Organizations
GYN ONC Clinical Trials
Hotel Tax Exempt Certificate
IBS definition
IHOP - 01.01.03 - Institutional Handbook of Operating Procesdures (Process)
IHOP - 01.01.03 - Institutional Handbook of Operating Procedures (Process Diagram-Visio)
IHOP - 01.01.03 - Institutional Handbook of Operating Procedures (Diagram)
IHOP - 01.01.03 - Institutional Handbook of Operating Procedures (Policy Template)
IHOP - 02.01.05 - Business Continuity Plan
IHOP - 02.06.06 - Posting of Notices on Institutional Communication Venues
IHOP - 02.06.07 - Fundraising Projects Benefiting UTMB Budget Worksheet (sample)
IHOP - 02.06.07 - Fundraising Projects Benefiting UTMB Proposal Form
IHOP - 02.07.02 - Space Management (UTMB Space Guidelines)
IHOP - 02.07.02 - Space Mangement Research Policy Attachment to Amendment
IHOP - 02.07.02 - Space Request Process and Form
IHOP - 02.17.07 - Wikipedia Examples
IHOP - 02.19.06 - Information Resource Security (Violation of Policy)
IHOP - 02.19.07 - Use of Social Media (Tips)
IHOP - 03.01.06 - Personal Appearance (Uniform Verfication)
IHOP - 03.01.09 - Discipline, Dismissal and Appeal for Classified Employees (Policies that Delineate Professional Behavior)
IHOP - 03.03.02 - Faculty and Administrative & Professional Recruitment (Definition)
IHOP - 03.03.09 - Reduction in Force (RIF) Criteria
IHOP - 03.03.09 - Reduction in Force (RIF) Guidelines
IHOP - 03.03.09 - Reduction in Force (RIF) Guidelines1
IHOP - 03.03.09 - Reduction in Force (RIF) Guidelines2
IHOP - 03.04.07 - Longevity Pay (Schedule)
IHOP - 03.07.01 - Fitness for Duty (Observation Form)
IHOP - 03.07.08 - Worksite Breastfeeding Lactation Room Guidelines
IHOP - 04.04.17 - Membership Organization Dues (Chart) Duplicate
IHOP - 04.04.17 - Membership Organization Dues - (Chart)
IHOP - 04.05.07 - Cost Sharing Policy (Accounting Treatment for Cost Sharing)
IHOP - 05.03.08 - Grievance Panel Hearing Procedures
IHOP - 05.03.14 - Faculty Ombudsperson Policy (Position Description)
IHOP - 05.07.05 - Policy on Integrity in Research - Assessment, Inquiry and Investigation Procedures Manual
IHOP - 06.01.03 - Appeal of a Determination by the Office of Institutional Compliance (ICC Repeal Request)
IHOP - 06.02.01 - Authorization Validation Checklist
IHOP - 06.02.01 - Use and Disclosure of PHI Based on Patient Authorization (Form)
IHOP - 06.02.01 - Use of Disclosure of PHI Based on Patient Authorization (Elements)
IHOP - 06.02.09 - Fax Transmittal of PHI (Cover Letter)
IHOP - 06.02.09 - Fax Transmittal of PHI (Fax Cover Sheet)
IHOP - 06.02.24 - Removal of Protected Health Information from UTMB Facilities (Request for Use of PHI Offsite Form)
IHOP - 06.03.09 - Details Outpatient ABN
IHOP - 07.01.01 - Appendix A
IHOP - 07.01.01 - Appendix B
IHOP - 07.01.01 - Appendix C
IHOP - 07.01.01 - Appendix D
IHOP - 07.01.01 - Appendix E
IHOP - 07.01.01 - School of Nursing Essential Functions
IHOP - 07.01.01 - Student Request for Accommodations
IHOP - 07.01.03 - Documentation of Non Academic Concerns
IHOP - 07.01.10 - Student Accident and Injury Reporting (Form)
IHOP - 07.01.13 - Documentation of Non Academic Concerns Form
IHOP - 07.01.20 - SHP Grading and Evaluation
IHOP - 07.01.20 - SHP Student Appeals of Grading and Unsatisfactory Academic Performance (Grievance Steps)
IHOP - 07.01.29 - UTMB Student Health Inaurance Policy (Acknowledgement Form)
IHOP - 08.01.01 - Policy and guidelines on AIDS, HIV and Hepatitis B (TCPHP Testing of Pregnant Women)
IHOP - 08.01.01 - Policy and Guidelines on AIDS, HIV, and Hepatitis B (Outbreak of Hep A)
IHOP - 08.01.02 - OGG feedback Safe Patient Handling
IHOP - 08.01.05 - Fire Alarm and Incident Response Policy (Drills)
IHOP - 08.01.05 - Fire Alarm and Incident Response Policy (PASS)
IHOP - 08.01.05 - Fire Alarm and Incident Response Policy (RACE)
IHOP - 08.01.05 - Fire Alarm and Incident Response Policy (Response)
IHOP - 08.01.23 - Above Ceiling Work Policy for Healthcare Buildings (Permit)
IHOP - 08.02.01 - Threatening Situations (Timely Warnings, Emergency Notifications and Evacuations)
IHOP - 08.02.01 - Threatening Situtations (Activating the Alert System)
IHOP - 08.02.02 - Campus Security Reporting (UTMBs Campus Security Authorities)
IHOP - 08.02.07 - Security Associated with Offender Correctional Patients
IHOP - 08.03.01 - Resource Conservation Policy (FOAM Guidelines)
IHOP - 09.01.08 - Inpatient Absence for Personal or Therapeutic Reasons (Off Unit Log)
IHOP - 09.01.23 - MICU CCU Admission Criteria (Classification of P and V)
IHOP - 09.01.32 - Process for Testing Dr. Pink System
IHOP - 09.02.06 - MED-REQ
IHOP - 09.02.06 - Research Request form
IHOP - 09.02.07 - Use and Disclosure of Inpatient Protected Health Information (Discharge Needs Assessment Factors)
IHOP - 09.02.08 - Medial Record Forms Management (Guidelines) doc 2007
IHOP - 09.02.08 - Medical Record Form Management (Guidelines)
IHOP - 09.02.15 - Medical Record Documentation (Guidelines for Copying Pasting Medical Records)
IHOP - 09.02.15 - Medical Record Documentation (Style Guide)
IHOP - 09.02.15 - Medical Record Documentation (Style Guide) Duplicate
IHOP - 09.02.16 - Scanning Protected Health Information to Epic (Do's and Don'ts of Scanning)
IHOP - 09.02.20 - Email Agreement
IHOP - 09.02.20 - Physician-Patient Email Communication (Email Agreement)
IHOP - 09.02.20 - Physician-Patient Email Communication (Email Tracking Tool)
IHOP - 09.02.21 - Medical Record Number Assignment (Tips)
IHOP - 09.03.02 - Use of Photgraph, Video Audio Recordings and or Televising Patients (Consent Form)
IHOP - 09.03.02 - Use of Photography, Video Audio Recordings, and or Televising Patients (GNL Photography Policy)
IHOP - 09.03.04 - Law Enforcement Request for Records (SANE)
IHOP - 09.03.04 - Texas Department of Family and Protective Services p1
IHOP - 09.03.09 - Assessment Criteria
IHOP - 09.03.09 - Definitions - Abuse Neglect and Exploitation of Elderly or Disabled Persons
IHOP - 09.03.09 - Definitions of Child Abuse and Neglect
IHOP - 09.03.09 - Examples LINK
IHOP - 09.03.09 - Reporting Suspected Abuse, Neglect, and Exploitation of Children, the Elderly and or Disabled Persons (Assessment Criteria)
IHOP - 09.03.32 - SBS Medical_Disclosure_English
IHOP - 09.03.32 - SBS Medical_Disclosure_Spanish
IHOP - 09.07.01 - Hospital and Ambulatory Services Visitation (Examples)
IHOP - 09.07.02 - Vendor Visitation UTMB Clinical Enterprise (Vendor Procedures)
IHOP - 09.07.02 - Vendor Visitation UTMB Clinical Enterprise (Vendor Release Form)
IHOP - 09.07.02 - Vendor Visitation UTMB Clinical Enterprise (Vendor Visitation Form)
IHOP - 09.08.02 - UTMB Health Charity Care and Financial Assistance Policy (Asset Procedure)
IHOP - 09.08.02 - UTMB Health Charity Care and Financial Assistance Policy (Disposable Income Worksheet)
IHOP - 09.08.02 - UTMB Health Charity Care and Financial Assistance Policy (Federal Poverty Index)
IHOP - 09.08.02 - UTMB Health Charity Care and Financial Assistance Policy (Indigent Requirements and Application Process)
IHOP - 09.11.01 - Licensure Certification Registration of Healthcare Professionals (Departmental Certifications)
IHOP - 09.11.04 - Standing Delegated Order Flow Diagram
IHOP - 09.11.05 - Physician Orders (Adult Primary Care Prescription Refill Guidelines for Ambulatory Services)
IHOP - 09.13.04 - POCT Responsibilities
IHOP - 09.13.10 - Changing Patient Identifiers
IHOP - 09.13.10 - Changing Patient Identifiers - Attachment A
IHOP - 09.13.10 - Changing Patient Identifiers - Attachment B
IHOP - 09.13.10 - Changing Patient Identifiers - Attachment C
IHOP - 09.13.10 - Changing Patient Identifiers - Attachment D
IHOP - 09.13.15 - Serological Testing for Syphilis, Hepatitis B, and HIV during Pregnancy and Delivery (HBConfirmation)
IHOP - 09.13.15 - Serological Testing for Syphilis, Hepatitis B, and HIV during Pregnancy and Delivery (HBsAg_Screening)
IHOP - 09.13.22 - Medical Equipment Plan (EOC) Master_Plan
IHOP - 09.13.25 - Universal Protocol for Invasive and Surgical Procedures (Alternative Process for Site Marking)
IHOP - 09.13.31 - Activation of the Medical Surgical and Obstetrical Rapid Response Teams (RRT) Guidelines
IHOP - 09.13.32 - Admission Decision Tree
IHOP - 09.13.32 - Exclusion Criteria1
IHOP - 09.13.32 - Inclusion Criteria
IHOP - 09.13.33 - Intraosseous Catheters (IO) Overview
IHOP - 09.13.35 - ANTICOAGULATION DISCHARGE ORDERS (3004003)
IHOP - 09.13.35 - Anticoagulation Follow-Up (26015)
IHOP - 09.13.35 - Anticoagulation for ACS ORDER SET-No Renal Failure (CrCl greater than 30ml min) (522)
IHOP - 09.13.35 - Anticoagulation for ACS ORDER SET-No Renal Failure (CrCl LESS than 30ml min) (521)
IHOP - 09.13.35 - Anticoagulation for DVT PE Order Set -Renal Failure (CrCl less than 30 mL min) (524)
IHOP - 09.13.35 - Anticoagulation for DVT PE ORDER SET-No Renal Failure (CrCl LESS than 30ml min) (523)
IHOP - 09.13.35 - Anticoagulation Initial (26014)
IHOP - 09.13.36 - OSA Screening Tool
IHOP - 09.13.37 - Tube Placement for Nutrition in Adults
IHOP - 09.13.39 - Humpty Dumpty Fall Assessment Scale
IHOP - 09.13.39 - Patient Falls Prevention Plan
IHOP - 09.13.40 - Blanket and Fluid Warmer Operating Temperatures (Guidelines)
IHOP - 09.15.01 - Disposition of Deseased Patients (Autopsy Services)
IHOP - 09.15.05 - Patients Initiating Advance Directives (Witnesses)
IHOP - 09.15.06 - Making and Documenting Treatment Decisions including Withholding or Withdrawing Life-Sustaining Treatment (Victory Lakes Surgical Center Consent Form)
IHOP - 09.15.10 - Donation After Cardiac Death (Postmortem Anatomical Gifts)
IHOP - 09.19.03 - Mobile Communication Devices Policy (Cellular Lease)
IHOP - 10.01.01 - Academic Program Evaluation (Critical Thinking Chart)
IHOP - 10.01.02 - UTMB Approval Process for New Educational Programs (Flow Diagram)
IHOP - 11.01.05 - Research Related Injury (Addendum A)
IHOP - 13.07.00 - RMCHP Assessment & Screening of Abuse
IHOP 06.02.32 - Verifying Requirements Prior to Disclosing Protected Health Information (PHI) Checklist
Illegal Drugs and Alcohol Use and Abuse
IncomeCalculationDocWorksheet
IncomeTaxProc
Inpatient Nursing Admission Assessment- Criteria for further assessment (4)
IP HEM ARGATROBAN WEIGHT-BASED DOSING FOR HIT (3000090)
LD Access Request Form
MediaAuthorization
MediaAuthorizationSpan
Medical Examiner
Medical Indigency worksheet
Medically Indigent Notification Letter
Month income calculation
Morse Fall Assessment Scale
OCRLetterviolence-1
Pager Lease
Patient dismissal letter A14
Patient Owned Medical Equipment CES form
PATIENT PLACEMENT FORM
Patient Services Complaint Process 2009
PG-Priority Index Definition
PP COBRA Premiums Paid by UTMB
Pre-existing Conditions of Primary Interest
Procedure for Clinical Assessment of Brain Death
Professionalism Agree Final
Registration for Eligibility of 3rd party Resources
Release of Forensic Photographs
Request for Dual Employment
Request for Non-IHOP Review
Request for Policy Review
Request for Use of PHI Offsite
Resource Conservation Guidelines
Restraint Comparison Table
Restraint Algorithms
Reversal of Anticoagulation-No indications for SQ adminisration of Vitamin K (525)
Roles and Responsibilities - Deceased Patients
RTOG Active and Pending Protocols CAMPUS
Screening Criteria for Communicable Diseases
Sexual Assault Prevention and Response
Space Planning Process (2013)
SUBCHAPTER C Texas Public Information Act Exceptions
Supervisor's Observation Report
Sutainability Steering Committee ReportJune 30REVISED (2)
TDP3 4BDonorVerificationForm
Telecommunications Services Request
Texas Administrative Code CHAPTER 21 Student Services
The certification process
Toluidine Blue Dye
UT SYSTEM POLICY ON SUSTAINABILITY PRACTICES-Assignments
UTMB Campaign Counting Guidelines
UTMB Health authorization for the release of photos
UTMB Health consent to photograph for TPO
UTMB Healthcare Buildings
UTMB Patient Absence Request Form 05PA

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