University of Nebraska Medical Center - User contributions [en]

Policies and Procedures

2026-09-24T21:07:04Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|09/17/26
|09/17/26
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/policies/#docaccess-a43f63f2683c00ed41b40cf3ebf8a93627427f63d8208959f090bd1c64744adf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/policies/#docaccess-84d14fb4cbe36b31a4b7361a9dcef822f521d718ae97a80a0d1126486a04e9ae Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|09/17/26
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|09/17/26
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|09/17/26
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|09/17/26
|-
|[[Export Control]]
|8005
|12/18/12
|08/08/26
|08/19/26
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|09/17/26
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|09/17/26
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|09/17/26
|09/17/26
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|09/17/26
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|09/17/26
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|09/17/26
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|09/17/26
|09/17/26
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|09/17/26
|08/19/26
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|09/17/26
|-
|[[Whistleblower]]
|8018
|04/11/19
|09/17/26
|09/27/26
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|09/17/26
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Disclosing Foreign Support and International Activities

2026-09-21T21:08:50Z

Mhurlocker:

Policies and Procedures

2026-09-21T20:49:13Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|09/17/26
|09/17/26
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/policies/#docaccess-a43f63f2683c00ed41b40cf3ebf8a93627427f63d8208959f090bd1c64744adf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity] for all NU campuses, Executive Memorandum No. 40
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-05-recruitment-and-selection-policy.pdf HR-05, Recruitment and Selection Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/policies/#docaccess-84d14fb4cbe36b31a4b7361a9dcef822f521d718ae97a80a0d1126486a04e9ae Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|09/17/26
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|09/17/26
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|09/17/26
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|09/17/26
|-
|[[Export Control]]
|8005
|12/18/12
|08/08/26
|08/19/26
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|09/17/26
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|09/17/26
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|09/17/26
|09/17/26
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|09/17/26
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|09/17/26
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|09/17/26
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|09/17/26
|09/17/26
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|09/17/26
|08/19/26
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|09/17/26
|-
|[[Whistleblower]]
|8018
|04/11/19
|09/17/26
|09/27/26
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|09/17/26
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Human Tissue Use and Transfer

2026-09-21T20:16:40Z

Mhurlocker: /* Policy */

Human Tissue Use and Transfer

2026-09-21T20:03:28Z

Mhurlocker:

Policies and Procedures

2026-09-21T20:02:57Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|09/17/26
|09/17/26
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-03-alternative-worksite-policy.pdf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity] for all NU campuses, Executive Memorandum No. 40
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-05-recruitment-and-selection-policy.pdf HR-05, Recruitment and Selection Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/voluntary-fte-reduction-program.pdf Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|09/17/26
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|09/17/26
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|09/17/26
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|09/17/26
|-
|[[Export Control]]
|8005
|12/18/12
|08/08/26
|08/19/26
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|09/17/26
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|09/17/26
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|09/17/26
|09/17/26
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|09/17/26
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|09/17/26
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|09/17/26
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|09/17/26
|09/17/26
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|07/09/24
|07/09/24
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|09/17/26
|-
|[[Whistleblower]]
|8018
|04/11/19
|09/17/26
|09/27/26
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|09/17/26
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Clinical Research and Clinical Trial Professional and Technical Fee Billing

2026-09-21T19:53:40Z

Mhurlocker: /* Qualified Clinical Trials or Research */

Policies and Procedures

2026-09-21T19:48:57Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|09/17/26
|09/17/26
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-03-alternative-worksite-policy.pdf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity] for all NU campuses, Executive Memorandum No. 40
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-05-recruitment-and-selection-policy.pdf HR-05, Recruitment and Selection Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/voluntary-fte-reduction-program.pdf Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|09/17/26
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|09/17/26
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|09/17/26
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|09/17/26
|-
|[[Export Control]]
|8005
|12/18/12
|08/08/26
|08/19/26
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|09/17/26
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|09/17/26
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|09/17/26
|09/17/26
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|09/17/26
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|09/17/26
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|09/17/26
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|07/21/23
|07/09/24
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|07/09/24
|07/09/24
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|09/17/26
|-
|[[Whistleblower]]
|8018
|04/11/19
|09/17/26
|09/27/26
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|09/17/26
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Outside Employment

2026-09-21T19:29:19Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="100%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:white; line-height:0.95em; border:solid 2px #A3B1BF; border-bottom:0; font-weight:bold;" width="20">
[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td>
</tr>
</table>
<br />
[[Employee Leave]] | [[Drug Free Campus]] | [[Employment]] | [[Work Schedules]] | [[Employee Separation]] | [[Compensation Administration]] | [[Dress Code]] | [[Background Check]] | [[Recurring/Additional Payment]] | [[Employee Grievance Process]] | [[Reduction-in-Force]] | [[Outside Employment]] | [[Political Activities]] | [[Employee/Dependent Scholarship]] | [[Employee Recognition and Reward]] | [[Performance Evaluation]] | [[Corrective/Disciplinary Action]] | [[Non-Discrimination and Harassment]] | [[Tobacco-Free Campus]] | [[Nepotism]] | [[Influenza]] | [[Consensual Relationships]] | [[AIDS, HIV, and Other Bloodborne Pathogens]] | [[Personnel Action Documentation]] | [[Fitness for Duty]] | [[Sexual Misconduct]] | [[Personnel Files]] | [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-03-alternative-worksite-policy.pdf NU Alternate Work Site Policy] | [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity]<br /><br />
Policy No.: '''1049'''<br />
Effective Date: '''11/01/06'''<br />
Revised Date: '''09/17/26'''<br />
Reviewed Date: '''09/17/26'''<br />
<br />
<big>'''Outside Employment Policy'''</big>
== Basis for Policy ==
The [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/board-governing-documents/board-of-regents-policies.pdf University of Nebraska Board of Regents Policies] (pages RP-95, 98-100) and the
[https://nebraska.edu/docs/legal/GCGuidanceOutsideEmployment-3-4-5.pdf University of Nebraska Board of Regents Bylaws 3.4.5] require that:

:Staff members employed on a part-time basis by the University, such as practicing lawyers or physicians, may engage in outside employment or activities unless it is expressly stipulated to the contrary in the conditions of employment. <br />

:Staff members employed by the University, other than those covered in the preceding paragraph, shall be encouraged to engage in professional activities outside the University as a means of contributing to the economic growth and development of the state as well as broadening their experience and keeping them abreast of the latest developments in their specialized fields; provided such activities do not interfere with their regular duties at the University, or represent a conflict of interest. Staff members may accept temporary or occasional employment for such professional services when such employment is approved by the dean of the college or director of the institute involved and approved by the Chancellor.
== Policy ==
#The University of Nebraska Medical Center (UNMC) declares and affirms a policy that encourages employees to engage in professional activities outside UNMC as a means of broadening their experience and keeping them abreast of the latest developments in their specialized fields. Employees may be employed by other external organizations or at other institutions provided such activities do not interfere with their regular duties at UNMC or create a conflict of interest (see UNMC Policy No. 8010, [[Conflict of Interest]]).
#UNMC must be considered the employee’s primary employer. While the Outside Employment policy is not intended to restrict an employee’s personal rights, UNMC employment will take precedence in all matters involving work issues. Outside employment will not be considered a valid reason for absenteeism, tardiness, or poor job performance.
#Full-time academic and administrative and managerial professional staff shall complete an Application for Authorization to Engage in Outside Professional Activity Form prior to engaging in outside professional employment. The Application for Authorization to Engage in Outside Professional Activity Form shall be submitted for no greater than a 12 month period. If an applicant is still actively participating in the submitted activity after the approved 12 month period, a new Application for Authorization to Engage in Outside Professional Activity Form shall be submitted via COI Smart. Part-time academic and administrative and managerial staff are not required to complete the form. Log on to COI-Smart at https://unmc.coi-smart.com/ utilizing your campus credentials to access the electronic Application for Authorization to Engage in Outside Professional Activity Form. Outside employment approval is not required for United States-based institutions of higher education, academic medical centers or governmental agencies.
#The Application shall be reviewed by supervisory personnel. Vice Chancellors, deans, directors, and department chairs have primary responsibility for reviewing the specific nature of each proposed outside professional activity within their respective areas of responsibility. They may deny approval for any activity that would interfere with normal UNMC duties.
#Applications shall be forwarded to the Chancellor for final campus review. Applications requiring Board of Regents approval will be forwarded to Central Administration.
#Once final approval has been received, the Compliance Department shall retain the original form and provide copies to the department head and the applicant.
==Additional Information==
*Compliance Department, 402-559-3784
*[mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer]
*UNMC Policy No. 8010, [[Conflict of Interest]]
*[https://unmc.coi-smart.com Application for Authorization to Engage in Outside Professional Activity]
*[https://nebraska.edu/regents/bylaws-policies-and-rules/#docaccess-f46e4a7f9ec5419abaf7e1cacc2c3401c70296a663ae9c4c115c20b56fc299ec University of Nebraska Board of Regents Policies]
<br />
This page maintained by [mailto:mhurlocker@unmc.edu mh].<br />

Policies and Procedures

2026-09-21T19:20:32Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|09/17/26
|09/17/26
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-03-alternative-worksite-policy.pdf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity] for all NU campuses, Executive Memorandum No. 40
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-05-recruitment-and-selection-policy.pdf HR-05, Recruitment and Selection Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/voluntary-fte-reduction-program.pdf Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|09/17/26
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|09/17/26
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|09/17/26
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|09/17/26
|-
|[[Export Control]]
|8005
|12/18/12
|08/08/26
|08/19/26
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|09/17/26
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|09/17/26
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|07/09/24
|07/09/24
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|09/17/26
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|09/17/26
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|09/17/26
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|07/21/23
|07/09/24
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|07/09/24
|07/09/24
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|09/17/26
|-
|[[Whistleblower]]
|8018
|04/11/19
|09/17/26
|09/27/26
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|09/17/26
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Policies and Procedures

2026-09-21T19:09:05Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|07/26/21
|07/09/24
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-03-alternative-worksite-policy.pdf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity] for all NU campuses, Executive Memorandum No. 40
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-05-recruitment-and-selection-policy.pdf HR-05, Recruitment and Selection Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/voluntary-fte-reduction-program.pdf Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|09/17/26
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|09/17/26
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|09/17/26
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|09/17/26
|-
|[[Export Control]]
|8005
|12/18/12
|08/08/26
|08/19/26
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|09/17/26
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|09/17/26
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|07/09/24
|07/09/24
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|09/17/26
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|09/17/26
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|09/17/26
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|07/21/23
|07/09/24
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|07/09/24
|07/09/24
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|09/17/26
|-
|[[Whistleblower]]
|8018
|04/11/19
|09/17/26
|09/27/26
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|09/17/26
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Whistleblower

2026-09-21T19:04:47Z

Mhurlocker:

Whistleblower

2026-09-21T19:03:04Z

Mhurlocker:

Policies and Procedures

2026-09-21T17:10:15Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|07/26/21
|07/09/24
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-03-alternative-worksite-policy.pdf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity] for all NU campuses, Executive Memorandum No. 40
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-05-recruitment-and-selection-policy.pdf HR-05, Recruitment and Selection Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/voluntary-fte-reduction-program.pdf Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|09/17/26
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|09/17/26
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|09/17/26
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|09/17/26
|-
|[[Export Control]]
|8005
|12/18/12
|08/08/26
|08/19/26
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|09/17/26
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|09/17/26
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|07/09/24
|07/09/24
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|09/17/26
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|09/17/26
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|09/17/26
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|07/21/23
|07/09/24
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|07/09/24
|07/09/24
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|09/17/26
|-
|[[Whistleblower]]
|8018
|04/11/19
|04/11/19
|07/09/24
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|09/17/26
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Export Control

2026-09-21T17:08:53Z

Mhurlocker:

Electronic Digital Signatures and Records

2026-09-21T16:19:53Z

Mhurlocker:

Credit Hour Definition

2026-09-21T16:19:01Z

Mhurlocker:

Principles of Financial Stewardship

2026-09-21T16:18:22Z

Mhurlocker:

Red Flag Identity Theft Prevention Program

2026-09-21T16:11:09Z

Mhurlocker:

Contracts

2026-09-21T16:10:34Z

Mhurlocker:

Use of Human Anatomical Material

2026-09-21T16:09:34Z

Mhurlocker:

Code of Conduct

2026-09-21T16:07:47Z

Mhurlocker:

Research Integrity

2026-09-21T16:06:09Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="100%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF" width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF" width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF" width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:white; line-height:0.95em; border:solid 2px #A3B1BF; border-bottom:0; font-weight:bold;" width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF" width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF" width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF" width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF" width="20">[[Faculty]]</td>
</tr>
</table>
<br />
[[Compliance Program]] | [[Compliance Hotline]] | [[Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | [[Electronic Digital Signatures and Records]] | [[Utilizing Generative AI|UNMC AI Use Guidelines]]<br />
<br />
Policy No.: '''8003'''<br />
Effective Date: '''02/11/05'''<br />
Revised Date: '''10/06/25'''<br />
Reviewed Date: '''09/17/26'''<br /> <br />
<big>'''Research Integrity Policy'''</big>
== Basis for Policy ==
The University of Nebraska Medical Center (UNMC) is committed to maintaining an academic environment based on honesty, integrity and ethical conduct. UNMC promotes an environment of productivity, creativity, and academic freedom, while establishing firm expectations that individuals will not commit research misconduct.<br />
<br />
UNMC is responsible for the inquiry, investigation and adjudication of alleged research misconduct, and, in appropriate cases, taking corrective action. As a recipient of federal research funds, UNMC must comply with federal policies and regulations on responding to allegations of research misconduct including, without limitation:
*“Public Health Service Policies on Research Misconduct”, 42 CFR Part 93, Subpart A, Public Health Service regulations
*"Federal Policy on Research Misconduct", Executive Office of the President, 65 Fed. Reg. No. 235, December 6, 2000, Office of Science and Technology Policy
*"Research Misconduct", 45 CFR Part. 689, National Science Foundation regulations
== Scope ==
This policy applies to all individuals at UNMC engaged in research, including non-funded projects, projects supported by the Public Health Service (PHS), the National Science Foundation (NSF), other governmental entities and private funding sources. This policy applies to any person paid by, under the control of, or affiliated with UNMC, such as faculty, trainees, technicians, other staff members, students, fellows, and visiting scientist. If an allegation of research misconduct involves collaborators from an institution other than UNMC, the process under “Allegation Involving Multiple Institutions” below will be followed.

Without limitation, this policy applies to:

* Applications or proposals for support for research, research training, or activities related to research or research training in areas including, but not limited to biomedical, clinical, translational, behavioral, and social sciences, including education.
* Biomedical, clinical, translational, behavioral, educational and other social sciences research.
* Biomedical, clinical, translational, behavioral, educational and other social sciences research training programs.
* Activities that are related to biomedical, clinical, translational, behavioral, educational, or other social sciences research or research training, such as, but not limited to, the operation of tissue and data banks or the dissemination of research information.
* Research records produced during research, research training, or activities related to that research or research training.
* Research proposed, performed, reviewed, or reported, as well as any research record generated from that research, regardless of whether an application or proposal for federal funds resulted in an awarded grant, contract, cooperative agreement, subaward, or other form of support.

== Time Limitation ==
The Research Integrity Officer may dismiss an allegation of research misconduct brought more than six (6) years after the alleged research misconduct occurred, unless one of the following exceptions applies:

1. Subsequent Use Exception: The six (6) year time limit does not apply if the respondent continues or renews any incident of alleged research misconduct that occurred before the six (6)-year limitation through the use of, republication of, or citation to the portion(s) of the research record (''e.g.,'' processed data, journal articles, funding proposals, data repositories) alleged to have been fabricated, falsified, or plagiarized, for the potential benefit of the respondent.

* When the respondent uses, republishes, or cites to the portion(s) of the research record that is(are) alleged to have been fabricated, falsified, or plagiarized, in submitted or published manuscripts, submitted grant applications, progress reports submitted to grant funding agencies, posters, presentations, or other research records within six (6) years of when the allegations were received by UNMC, this exception applies.
* If research misconduct appears to fall within the subsequent use exception, but the Research Integrity Officer determines the exception does not apply, the Research Integrity Officer will document its determination that the exception does not apply.

2. Public Health or Safety Exception: The six (6) year time limit does not apply if the Research Integrity Officer, following consultation with the Office of Research Integrity, determines that the alleged research misconduct, if it occurred, would possibly have a substantial adverse effect on the health or safety of the public.

== Definitions ==
'''''Accepted practices of the relevant research community''''' means those practices established by [https://www.ecfr.gov/current/title-42/part-93 42 CFR part 93] and by PHS funding components or other funding agencies, as applicable, as well as commonly accepted professional codes or norms within the overarching community of researchers and institutions that apply for and receive federal awards.

'''''Allegation''''' means any disclosure of possible research misconduct through any means of communication and brought directly to the attention of a UNMC official.

'''''Assessment''''' means a consideration of whether an allegation of research misconduct appears to fall within the definition of research misconduct; appears to involve research, research training, or activities related to that research or research training; and is sufficiently credible and specific so that potential evidence of research misconduct may be identified. The assessment only involves the review of readily accessible information relevant to the allegation.

'''''Complainant''''' is the individual(s) who make(s) an allegation of research misconduct.

'''''Compliance Officer''''' means the individual with primary responsibility for overseeing compliance with UNMC’s policies and procedures.

'''''Conflict of Interest''''' means an unresolved personal, professional, or financial conflict of interest involving the complainant, respondent, or any witness or in the underlying research.

'''''Day''''' means calendar day unless otherwise specified. If a deadline falls on a Saturday, Sunday, or Federal holiday, the deadline will be extended to the next day that is not a Saturday, Sunday, or Federal holiday.

'''''Evidence''''' means anything offered or obtained during a research misconduct proceeding that tends to prove or disprove the existence of an alleged fact. Evidence includes documents, whether in hard copy or electronic form, information, tangible items, and testimony.

'''''Fabrication''''' means making up data or results and recording or reporting them.

'''''Falsification''''' means manipulating research materials, equipment, or processes, or changing or omitting data or results such that the research is not accurately represented in the research record.

'''''Good faith''''' as applied to a complainant or witness, means having a reasonable belief in the truth of one's allegation or testimony based on the information known to the complainant or witness at the time. An allegation or cooperation with a research misconduct proceeding is not in good faith if made with knowledge of or reckless disregard for information that would negate the allegation or testimony. Good faith as applied to a committee member means cooperating with the research misconduct proceeding by impartially carrying out the duties assigned for the purpose of helping UNMC meet its responsibilities under this part. A committee member does not act in good faith if their acts or omissions during the research misconduct proceedings are dishonest or influenced by personal, professional, or financial conflicts of interest with those involved in the research misconduct proceeding.

'''''Inquiry''''' means preliminary information-gathering and preliminary fact-finding in accordance with applicable law to determine whether an allegation of research misconduct warrants investigation.

'''''Institutional Deciding Official''''' is the UNMC official who makes final determinations on allegations of research misconduct and any institutional administrative actions. The Institutional Deciding Official will not be the same individual as the Research Integrity Officer. The Institutional Deciding Official is ordinarily the Chancellor of UNMC or his/her designee.

'''''Institutional record''''' means the institutional record comprised of:

(a) The records that UNMC compiled or generated during the research misconduct proceeding, except records UNMC did not consider or rely on. These records include, but are not limited to:

# Documentation of the assessment.
# If an inquiry is conducted, the inquiry report and all records (other than drafts of the report) considered or relied on during the inquiry, including, but not limited to, research records and the transcripts of any transcribed interviews conducted during the inquiry, information the respondent provided to the institution, and the documentation of any decision not to investigate.
# If an investigation is conducted, the investigation report and all records (other than drafts of the report) considered or relied on during the investigation, including, but not limited to, research records, the transcripts of each interview conducted, and information the respondent provided to the institution.
# Decision(s) by the Institutional Deciding Official.

(b) A single index listing all the research records and evidence that UNMC compiled during the research misconduct proceeding, except records UNMC did not consider or rely on.

(c) A general description of the records that were sequestered but not considered or relied on.

'''''Intentionally''''' means to act with the aim of carrying out the act.

'''''Investigation''''' means the formal development of a factual record and the examination of that record leading to a decision to recommend or not a finding of research misconduct and may include a recommendation for other appropriate actions, including administrative action.

'''''Knowingly''''' means to act with awareness of the act.

'''''ORI''''' means the Office of Research Integrity in the U.S. Department of Health and Human Services (DHHS). ORI is responsible for the scientific misconduct and research integrity activities of the U.S. Public Health Service (PHS).

'''''Plagiarism''''' means the appropriation of another person's ideas, processes, results, or words without giving appropriate credit.

(a) Plagiarism includes the unattributed verbatim or nearly verbatim copying of sentences and paragraphs from another's work that materially misleads the reader regarding the contributions of the author. It does not include the limited use of identical or nearly identical phrases that describe a commonly used methodology.

(b) Plagiarism does not include self-plagiarism or authorship or credit disputes, including disputes among former collaborators who participated jointly in the development or conduct of a research project. Self-plagiarism and authorship disputes do not meet the definition of research misconduct.

'''''Preponderance of the evidence''''' means proof by evidence that, compared with evidence opposing it, leads to the conclusion that the fact at issue is more likely true than not.

'''''Recklessly''''' means to propose, perform, or review research, or report research results, with indifference to a known risk of fabrication, falsification, or plagiarism.

'''''Research''''' means a systematic experiment, study, evaluation, demonstration, survey or other process of inquiry designed to generate new knowledge or to confirm, refine, or apply existing knowledge. It encompasses a broad range of disciplines, including but not limited to biomedical, clinical, translational, behavioral, educational, and social sciences, and may comprise many different approaches appropriate to the respective discipline. Research may involve observation, experimentation, analysis, evaluation, or synthesis, and is conducted with the goal of expanding scientific understanding, informing evidence-based practice, improving population-based outcomes, and/or contributing to the public good.

'''''Research Integrity Officer''''' means the institutional official with primary responsibility for implementation of UNMC’s policies and procedures on research misconduct. Among other things, the Research Integrity Officer performs the duties described in this policy.

'''''Research Misconduct''''' means fabrication, falsification, or plagiarism in proposing, performing, or reviewing research, or in reporting research results. Research misconduct does not include honest error or differences of opinion.

'''''Research Record''''' means the record of data or results that embody the facts resulting from scientific inquiry. Data or results may be in physical or electronic form. Examples of items, materials, or information that may be considered part of the research record include, but are not limited to, research proposals, raw data, processed data, clinical research records, laboratory records, study records, laboratory notebooks, progress reports, manuscripts, abstracts, theses, dissertations, records of oral presentations, online content, lab meeting reports, and journal articles.

'''''Respondent''''' means the individual against whom an allegation of research misconduct is directed or who is the subject of a research misconduct proceeding. There can be more than one respondent in any inquiry or investigation.

'''''Retaliation''''' means any adverse action taken against a complainant, witness, committee member, or other individual acting in their institutional capacity by an institution or one of its members in response to (a) a good faith allegation of research misconduct; or (b) good faith cooperation with a research misconduct proceeding; or (c) good faith implementation of the research integrity policy or the processes outlined therein.

== Responsibility for Implementation ==
The Chancellor of UNMC or designee, typically the Compliance Officer, is responsible for assuring compliance with federal, state, and university policies and procedures governing the responsible and ethical conduct of research. The Chancellor of UNMC or designee delegates responsibility for responding to allegations of research misconduct to the Research Integrity Officer or designee, who shall be responsible for ensuring that inquiries and investigations thoroughly evaluate the facts while protecting the rights of the parties involved in the alleged misconduct.
== General Policies==
===Research Misconduct Prohibited, Standard of Proof===
*UNMC prohibits research misconduct. Individuals subject to this policy found to have committed research misconduct shall be subject to sanctions up to and including termination.
*A finding of research misconduct requires that:
:(a) there be a significant departure from accepted practices of the relevant research community; and
:(b) the respondent committed the research misconduct intentionally, knowingly, or recklessly; and
:(c) the allegation be proven by preponderance of the evidence
*UNMC bears the burden of proof for making a finding of research misconduct
** A respondent’s destruction of research records documenting the questioned research is evidence of research misconduct where UNMC establishes by a preponderance of the evidence that the respondent intentionally or knowingly destroyed records after being informed of the research misconduct allegations.
** A respondent’s failure to provide records documenting the questioned research is evidence of research misconduct where the respondent claims to possess the records but refuses to provide them upon request.
** The absence of or failure to retain records over time that violates retention requirements is not necessarily evidence of misconduct and will not automatically lead to an adverse inference. The facts and circumstances surrounding the absence of or failure to retain records must be examined to determine whether absence or failure constitutes evidence of research misconduct.

*A respondent has the burden of going forward with and the burden of proving, by a preponderance of the evidence, any and all affirmative defenses raised (such as honest error).
===Duty to Report Research Misconduct===
All individuals subject to this policy, including, without limitation, all employees, students or other individuals associated with UNMC shall report observed, suspected, or apparent research misconduct in accordance with the procedures outlined in this policy.
===Duty to Cooperate with Inquiries and Investigations===
All individuals subject to this policy shall cooperate with the Research Integrity Officer and other institutional officials in the review of allegations and the conduct of inquiries and investigations. Institutional members, including respondents, have an obligation to provide all requested evidence and information related to such inquiries or investigations. Cooperation includes, without limitation, maintaining confidentiality and deferring to the process outlined in this policy, which is designed both to hold researchers accountable and to prevent unjust harm to a career as a result of an allegation that does not ultimately result in a finding of research misconduct. Failure to cooperate may result in sanctions pursuant to appliable UNMC policy including, but not limited to, the UNMC Code of Conduct or Student Code of Conduct.
===Duty to Maintain Confidentiality===
Allegations of research misconduct (even when ultimately disproven) can have serious career consequences for a researcher. Therefore, to the maximum extent permitted by applicable law, all individuals subject to this policy shall maintain the strict confidentiality of any information relating to allegations of research misconduct or a research misconduct proceeding and shall disclose such information only to those with a need to know as determined by UNMC. While conducting research misconduct proceedings, the Research Integrity Officer or designee shall limit disclosure of the identity of respondents, complainants, and witnesses to those who need to know, as determined by UNMC, in order to carry out a thorough, competent, objective and fair research misconduct proceeding, and, except as otherwise prescribed by law, limit the disclosure of records or evidence from which research subjects might be identified to those who need to know in order to carry out a research misconduct proceeding. The Research Integrity Officer or designee may use written confidentiality agreements or other mechanisms to implement this section. Inappropriate dissemination of information can result in sanctions up to and including termination.

For purposes of this policy, those who may need to know could include institutional review boards, journals, editors, publishers, co-authors, and collaborating institutions. Furthermore, this policy does not prohibit UNMC from managing published data or acknowledging that data may be unreliable. UNMC must disclose the identity of respondents, complainants, or other relevant persons to ORI pursuant to an ORI review of research misconduct proceedings under this policy.

The limitation on disclosure of the identity of respondents, complainants, and witnesses no longer applies once UNMC has made a final determination of research misconduct findings. However, other obligations of confidentiality may limit UNMC’s disclosure even after final determination. Any disclosure of the identity of a respondent, complainant or witness will only be made after consultation with the Research Integrity Officer or designee and, if needed, legal counsel.

===Rights and Responsibilities of Complainant ===
The complainant is responsible for making allegations in good faith, maintaining confidentiality, and cooperating with the inquiry and investigation. The complainant may be interviewed at the inquiry phase and shall be interviewed at the investigation phase as described below. The role of a complainant is not to act as special prosecutor; once a complainant makes an allegation of research misconduct, the complainant is responsible for providing evidence and information in connection with the response to the allegation but otherwise shall defer to, and cooperate with, UNMC’s review, adjudication and response to research misconduct as provided in this policy. A complainant shall not discuss the allegations of research misconduct outside the process.
=== Rights and Responsibilities of Respondent===
The respondent is responsible for maintaining confidentiality and cooperating with the conduct of an inquiry and investigation. The respondent shall ordinarily receive the procedural rights and protections set forth in this policy. A respondent may be accompanied by legal counsel of their own choosing and at their own expense during an interview conducted under this policy. Legal counsel may advise the respondent but may not question witnesses or otherwise take part in the proceedings.
===Retaliation Prohibited===
Retaliation against complainants, witnesses, or committee members or other individual acting in their institutional capacity in any way is prohibited. Any individual covered by this policy should immediately report any alleged or apparent retaliation against complainants, witnesses, or committee members to the Research Integrity Officer or designee. The Research Integrity Officer or designee shall review the matter and, as necessary, make all reasonable and practical efforts to counter any potential or actual retaliation and protect and restore the position and reputation of the person against whom the retaliation is directed.
===Research Integrity Officer Responsibilities===
The Research integrity Officer shall serve as the primary point of contact for implementation of this policy. The Research integrity Officer or designee shall perform the functions set forth below.
==Procedures==
===Reporting Misconduct===
All individuals subject to this policy shall report observed, suspected, or apparent research misconduct to the Research Integrity Officer by phone or email. [https://www.unmc.edu/academicaffairs/compliance/research-integrity.html (<nowiki>https://www.unmc.edu/academicaffairs/compliance/research-integrity.html</nowiki>)]

Observed, suspected, or apparent research misconduct can also be reported to the UNMC Compliance Hotline at 1-844-348-9584 or [http://www.nebraska.ethicspoint.com/ www.nebraska.ethicspoint.com.]

In determining whether an incident falls under this policy, an individual may refer to the definitions under this policy (e.g., authorship disputes and self-plagiarism do not fall under this policy) and review University of Nebraska Executive Memorandum No. 41, Policy on Research Data and Security (e.g., for questions regarding data ownership). If an individual is unsure whether the suspected incident falls within the definition of research misconduct, they may call the Research Integrity Officer to discuss the suspected misconduct informally, including anonymously or hypothetically. Such discussions shall ordinarily be confidential. If the circumstances do not meet the definition of research misconduct, the Research Integrity Officer or designee will refer the individual or allegation to other offices with responsibility for resolving the problem.

=== Allegations Involving Multiple Institutions ===
When allegations involve research conducted at multiple institutions, the Research Integrity Officer will communicate with the administrator charged with research integrity at the other institution(s). UNMC and the other institution(s) must determine whether a joint research misconduct proceeding will be conducted and, if so, designate one institution to serve as the lead institution. The lead institution will follow its research misconduct policies and procedures to conduct the proceeding as modified by the procedures included- immediately below in this paragraph as agreed to by the participating institutions. In a joint research misconduct proceeding, the lead institution should obtain research records and other evidence pertinent to the proceeding, including witness testimony, from the other relevant institution(s). By mutual agreement, the joint research misconduct proceeding may include committee members from the institutions involved. The determination of whether further inquiry and/or investigation is warranted, whether research misconduct occurred, and the institutional actions to be taken may be made by the institutions jointly or tasked to the lead institution.

Allegations involving research being conducted at more than one campus of the University of Nebraska will be treated as allegations involving multiple institutions.

=== Allegations Involving the Research Integrity Officer or Institutional Deciding Official ===
In the event an allegation of research misconduct is made against the Research Integrity Officer or Institutional Deciding Official, or the Research Integrity Officer or Institutional Deciding Official has a conflict of interest with the outcome of the assessment, inquiry, or investigation of an allegation, the Vice Chancellor for Research will appoint a substitute for the Research Integrity Officer or Institutional Deciding Official. If such a replacement is not possible, the Vice Chancellor for Research will confer with the Office of General Counsel to determine whether external resources will be engaged to complete the necessary process under this policy.

===Preliminary Assessment of Allegations===
Upon receiving an allegation of research misconduct, the Research Integrity Officer or designee shall assess the allegation as soon as is feasible (usually within 21 days of receipt of the allegation) to determine whether it falls within the definition of research misconduct, is within the scope of this policy, and is sufficiently credible and specific so that potential evidence of research misconduct may be identified. If so, the matter must proceed to an inquiry. The Research Integrity Officer or designee will document the assessment, including, in cases where an inquiry is not warranted, with sufficient detail to permit a later review by the ORI of the reasons why an inquiry was not conducted. If the identity of the complainant is known, the Research Integrity Officer or designee will notify the complainant of the outcome of the assessment.

Authorship or collaboration disputes and other matters that are not within the definition of research misconduct, as set forth in this policy, are not subject to this policy and shall be addressed through procedures outlined in the [https://info.unmc.edu/wiki/index.php/Faculty_Handbook UNMC Faculty Handbook] , University of Nebraska Student Code of Conduct [https://catalog.unmc.edu/general-information/student-policies-procedures/code-of-conduct/code-of-conduct.pdf (https://catalog.unmc.edu/general-information/student-policies-procedures/code-of-conduct/code-of-conduct.pdf)] and University of Nebraska Medical Center Code of Conduct (<nowiki>https://catalog.unmc.edu/general-information/student-policies-procedures/unmc-code-of-conduct/</nowiki>), as appropriate. Authorship guidelines are found at [https://wiki.unmc.edu/index.php/Authorship_Guidelines Authorship Guidelines - University of Nebraska Medical Center]

===Sequestration of Research Records===

* If an inquiry is warranted, on or before the date the respondent is notified of any allegation of research misconduct or the inquiry begins, the Research Integrity Officer or designee must take all reasonable and practical steps to obtain custody of all the research records and evidence needed to conduct the research misconduct proceeding, which may include copies of the data or other evidence so long as those copies are substantially equivalent in evidentiary value. This will include the inventory of records and evidence and sequestration of them in a secure manner. Where the research records or evidence encompasses scientific instruments shared by a number of users, custody may be limited to copies of the data or evidence of such instruments, so long as those copies are substantially equivalent to the evidentiary value of the instruments.

*The Research Integrity Officer or designee shall sequester any additional research records that become pertinent to an inquiry or investigation after the initial sequestration.
*The Research Integrity Officer or designee will review any physical evidence that will be sequestered to determine whether any physical evidence requires special conditions of storage and develop a plan for storage of any such physical evidence.
*The Research Integrity Officer or designee may consult with UNMC legal counsel, the Compliance Officer, and/or ORI for advice and assistance in this regard. Where appropriate, UNMC shall give the respondent copies of, or reasonable supervised access to the research records that have been sequestered.
*All sequestered evidence including physical objects must be maintained pursuant to the Record Retention provisions of this policy.
=== Inquiry===
====Initiation of the Inquiry====
At the time of or before beginning an inquiry, the Research Integrity Officer or designee must make a good faith effort to notify the respondent in writing, if the respondent is known. If the inquiry subsequently identifies additional respondents, they must be notified in writing. Only allegations specific to a particular respondent are to be included in the notification to that respondent.
====Purpose of the Inquiry====
The purpose of the inquiry is to conduct an initial review of the evidence to determine whether an allegation warrants an investigation. The purpose of the inquiry is not to reach a final conclusion about whether misconduct definitely occurred or who was responsible, and an inquiry does not require a full review of all the evidence related to the allegation. An investigation is warranted if it is determined:
:(1) there is a reasonable basis for concluding that the allegation falls within the definition of research misconduct; and,
:(2) the preliminary information-gathering and fact-finding indicate the allegation may have substance.
====Inquiry Process====
The Research Integrity Officer or designee shall conduct the inquiry. The Research Integrity Officer or designee may obtain assistance from one or more subject matter experts as may be necessary to conduct the inquiry. No person conducting or consulting on the inquiry will have an unresolved personal, professional, or financial conflict of interest with the complainant, respondent, or witnesses. The Research Integrity Officer or designee may interview the complainant, the respondent, and key witnesses as well as examine relevant research records and materials. If additional allegations are raised during the inquiry, the respondent(s) must be notified in writing of the additional allegations raised against them. The Research Integrity Officer or designee will evaluate the evidence and determine whether an investigation is warranted. Findings of research misconduct, including whether the alleged misconduct is intentional, knowing, or reckless, cannot be made through the inquiry process. The Research Integrity Officer or designee may make a determination of honest error as a result of the inquiry, which would not warrant an investigation.
====Written Report====
A written report shall be prepared in accordance with applicable legal requirements that includes the following information:

# the names, professional aliases, and position of the respondent and the complainant;
# a description of the allegations of research misconduct;
# the PHS or other governmental or third-party support including, for example, grant numbers, grant applications, contracts, and publications listing support;
# inventory of sequestered research records and other evidence and description of how sequestration was conducted;
# transcripts of any transcribed interviews;
# timeline and procedural history;
# any scientific or forensic analyses conducted;
# the basis for recommending or not recommending that the allegations warrant an investigation;
# if there is potential evidence of honest error or difference of opinion;
# any comments on the draft inquiry report by the respondent;
# any institutional actions implemented, including communications with journals or funding agencies; and
# if the inquiry took longer than 90 days to complete, the reasons for exceeding the 90-day period.

The respondent shall be given a copy of the draft inquiry report together with a copy of this policy. If the respondent chooses to comment on the report, they must submit a written response to the Research Integrity Officer or designee within fourteen (14) days after receiving the report in order for it to be made a part of the record. Based on the comments, the Research Integrity Officer or designee may revise the report as appropriate.

==== Decision by Deciding Official====
The Research Integrity Officer or designee will transmit the final inquiry report and any comments to the Institutional Deciding Official. The Institutional Deciding Official will make the determination of whether an investigation is warranted after reviewing the inquiry report and recommendation. If the findings from the inquiry indicate a reasonable basis for concluding that the allegation falls within the definition of research misconduct and the preliminary information-gathering and fact-finding from the inquiry indicate the allegation may have substance, then an investigation is warranted.
====Notification of Decision====
The Research Integrity Officer or designee will notify both the respondent and appropriate UNMC officials in writing of the Institutional Deciding Official's decision of whether to proceed with an investigation. The notice to the respondent must include a copy of the inquiry report, a copy of this Policy and, for PHS-funded research, a copy of or reference to 42 CFR Part 93. If the Institutional Deciding Official determines an investigation is warranted, the Research Integrity Officer or designee shall notify appropriate funding and oversight agencies (PHS, NSF, etc.) in writing of the decision and provide a copy of the inquiry report within thirty days after the Institutional Deciding Official’s decision.

The Research Integrity Officer or designee is not required to notify a complainant whether the inquiry found that an investigation is warranted. However, if the Research Integrity Officer or designee provides notice to one complainant in a case, they must provide notice, to the extent possible, to all complainants in a case.

====Time for Completion of Inquiry ====
The inquiry, including preparation of the final inquiry report and the decision of the Institutional Deciding Official, must be completed within 90 days of its initiation, unless the Research Integrity Officer or designee determines that circumstances warrant a longer period.
===Investigation===
====Initiation of the Investigation====
The investigation must begin within 30 days of the decision by the Institutional Deciding Official that the investigation is warranted. On or before the date on which the investigation begins, the Research Integrity Officer or designee must:
:(1) if applicable, notify ORI of the decision to begin the investigation and provide ORI a copy of the inquiry report (or comply with any other notice obligation to a government agency or other funder);
:(2) notify the respondent in writing of the allegations to be investigated.
====Purpose of the Investigation ====
The purpose of the investigation is to examine the allegations and evidence in detail and determine specifically whether misconduct has been committed, as defined in accordance with the standards of proof set forth in Section 1, by whom, and to what extent. The investigation committee shall pursue diligently all significant issues and leads discovered that are determined relevant to the investigation, including any evidence of additional instances of possible research misconduct, and continue the investigation to completion. If new allegations are identified, the Research Integrity Officer must also give the respondent written notice of such allegations within a reasonable amount of time of deciding to pursue allegations not addressed during the inquiry or in the initial notice of the investigation.
====Investigation Committee====
The Research Integrity Officer or designee, in consultation with other UNMC officials as appropriate, will appoint an investigation committee within ten (10) days after the notification to the respondent of the investigation or as soon thereafter as practicable. The investigation committee shall consist of at least three individuals who do not have unresolved personal, professional, or financial conflicts of interest in the case, who are unbiased, and who have the necessary expertise to evaluate the evidence and issues related to the allegations, interview the principals and key witnesses, and conduct the investigation. Individuals appointed to the investigation committee may have also participated in the inquiry. The Research Integrity Officer or designee will notify the respondent of the proposed committee membership. If the respondent submits a written objection to the appointed member of the inquiry committee based on bias or conflict of interest within five (5) days, the Institutional Deciding Official will determine whether to replace the challenged member with a qualified substitute.
====Investigation Process====
*The Research Integrity Officer or designee will provide a written charge to the committee. Such charge shall describe the allegations and related issues identified during the inquiry; identify the respondent; inform the committee that it must conduct the investigation as prescribed by this policy and in accordance with applicable law; define research misconduct; and instruct the investigation committee on the burden of proof. The charge shall state that the committee is to evaluate the evidence and testimony of the respondent, complainant, and key witnesses to determine whether, based on a preponderance of the evidence, research misconduct occurred and, if so, to what extent, who was responsible, and its seriousness. The committee will review procedures and standards for conduct of the investigation, including this policy and applicable federal regulations. The committee will be instructed that it is advisable to develop an investigation plan and as to the necessity for maintaining confidentiality.
*The investigation committee shall use diligent efforts to ensure that the investigation is impartial, unbiased, objective, thorough and sufficiently documented and shall include examination of all research records and evidence relevant to reaching a decision on the merits of each allegation.
* The investigation committee shall interview each respondent, complainant, and any other available person who has been reasonably identified as having information regarding any relevant aspects of the investigation, including witnesses identified by the respondent.

# Interviews during the investigation must be recorded and transcribed;
# Any exhibits shown to the interviewee during the interview must be numbered and referred to by that number in the interview;
# The transcript of the interview must be made available to the relevant interviewee for correction;
# The transcript(s) with any corrections and numbered exhibits must be included in the institutional record of the investigation; and
# The respondent must not be present during the witnesses’ interviews but must be provided a transcript of the interviews.

* If a respondent, complainant, or witness refuses an interview and or the respondent, complainant, witness or Investigation Committee requests another form of fact gathering, such as a response in writing to written questions, the Research Integrity Officer or designee will confer with the Office of Research Integrity to determine the permissibility of the proposed alternative to interview.

* If the investigation committee identifies additional respondents during the investigation, UNMC is not required to conduct a separate inquiry for each new respondent. If any additional respondent(s) are identified during the investigation, the Research Integrity Office must notify them of the allegation(s) and provide them an opportunity to respond consistent with this policy.
* The investigation committee shall determine whether, to what extent, and by whom research misconduct has been committed.

====Investigation Report====
Upon completion of the investigation, a written report for each respondent shall be prepared in accordance with applicable legal requirements. Such report shall, without limitation:
:(1) describe the nature of the allegation(s) of research misconduct, including identification of the respondent(s);
:(2) describe and document support for the research, including PHS or other funding agency support;
:(3) describe the specific allegations of research misconduct considered in the investigation;
:(4) describe composition of the investigation committee, including name(s), position(s), and subject matter expertise;
:(5) include the inventory of sequestered research records and other evidence, except records UNMC did not consider or rely on, with a description of how any sequestration was conducted during the investigation and including manuscripts and funding proposals that were considered or relied on in the investigation;
:(6) include transcripts of all interviews conducted;
:(7) identify any specific published papers, manuscripts submitted but not accepted for publication (including online publication), funding applications, progress reports, presentations, posters, or other research records that allegedly contain the falsified, fabricated, or plagiarized materials;
:(8) describe any scientific or forensic analyses conducted;
:(9) include the institutional policies and procedures under which the investigation was conducted;
:(10) include any comments made by the respondent and complainant on the draft investigation report and the investigation committee’s consideration of those comments;
:(11) include a statement of findings for each allegation of research misconduct identified during the investigation, summarizing the basis for the investigation committee’s decision and proposed corrective actions (if any). The statement shall include the identity of the individual(s) who committed the research misconduct, the type of misconduct (falsification, fabrication, or plagiarism), indicate whether the research misconduct was committed intentionally, knowingly, or recklessly; and state whether the requirements for finding research misconduct have been met. If the committee does not recommend a finding of research misconduct for an allegation, the investigation report must provide a detailed rationale; and
:(12) If the investigation took longer than 180 days to complete, include the reasons for exceeding the 180-day period.
:* The Research Integrity Officer or designee shall provide the respondent with a copy of the draft investigation report for comment and rebuttal. The respondent will be given thirty (30) days to review and comment on the draft report. The respondent will receive a copy of or have the opportunity to obtain supervised access to the evidence on which the report is based. The respondent shall submit comments to the Research Integrity Officer or designee within 30 days from the date the respondent received the draft report. The respondent's comments will be attached to the final report.
:* The investigation committee shall consider and address the respondent(s)’ comments on the draft report in connection with finalizing the report.
:* The draft investigation report will be transmitted to the University of Nebraska Office of the General Counsel for a review of its legal sufficiency.
====Decision by Deciding Official====
Within fifteen (15) days of receiving the investigation report, the Institutional Deciding Official will make a final determination whether to accept the final report and the recommended actions (with or without further modifications), or reject the recommendations and instruct the investigation committee to conduct further fact finding. If the Institutional Deciding Official's determination varies from that of the investigation committee, the Institutional Deciding Official shall explain in writing and in detail the basis for rendering a different decision.

The Institutional Deciding Official’s determination of whether research misconduct occurred is final for UNMC’s purposes and is independent of any finding from ORI or other funding agency regarding research misconduct. The lack of an ORI or other funding agency finding of research misconduct does not overturn UNMC’s determination that the conduct constituted research misconduct warranting remediation under this policy.

====Notification of Decision====
When a final decision is reached, the Research Integrity Officer or designee will normally notify both the respondent and the complainant in writing. After informing ORI, the Institutional Deciding Official shall determine whether law enforcement agencies, professional societies, professional licensing boards, editors of journals in which research misconduct may have been published, collaborators of the respondent in the work, or other relevant parties should be notified of the outcome of the case. The Research Integrity Officer or designee is responsible for ensuring compliance with all notification requirements of funding or sponsoring agencies.
====Time for Completion====
All aspects of the investigation shall be complete within 180 days of beginning it, including conducting the investigation, preparing the draft investigation report for each respondent, providing the draft report to each respondent for comment, and transmitting the institutional record including the final investigation report and decision by the Institutional Deciding Official to ORI or other funding agencies as required. If unable to complete the investigation within 180 days, the Research Integrity Officer or designee shall request an extension in writing that includes the circumstances or issues warranting additional time from any pertinent funding agencies as required. If an allegation involves research for which there is no external funding agency, the Research Integrity Officer or designee may extend the time to complete the investigation for a period reasonable under the circumstances in the Research Integrity Officer’s or designee’s discretion.
===Corrective Action===
Corrective action for research misconduct shall be based on the seriousness of the misconduct including, but not limited to, the degree to which the misconduct:

a) was intentional, knowing or reckless;

b) was an isolated event or part of a pattern; and

c) had significant impact on the research record, research subjects, other researchers, institutions, or the public welfare.

The range of corrective actions includes, but is not limited to, withdrawal or correction of all pending or published abstracts and papers emanating from the research where misconduct was found; removal of the responsible person from the particular project; special monitoring of future work; restitution of funds as appropriate; suspension or termination of an active award; termination, expulsion, suspension, leave without pay, and/or letters of reprimand. If the corrective action results in termination or other adverse change in an employee's terms and conditions of employment, the respondent may appeal the decision through the appropriate procedures contained in the Faculty Handbook or UNMC policy for non-faculty members. Students have appeal rights as outlined in the Student or Graduate Student Handbooks.

===Reporting to ORI or the Funding Agency===
The Research Integrity Officer or designee will make any notifications related to research misconduct required by the funding agency.

For PHS agencies subject to 42 CFR Part 93: The Research Integrity Officer or designee shall notify the ORI Director, in writing of the following events, among others:

* Decision to initiate a research misconduct investigation on or before the date the investigation begins;
* Transmission of the final investigation report;
* Decision to terminate an investigation for any reason without completing all regulatory requirements or as otherwise called for by this policy;
* Request for extension in the event that UNMC will not be able to complete the investigation within 180 days.

The Research Integrity Officer or designee shall provide immediate notice to the ORI Director, when:

* The health or safety of the public is at risk, including an immediate need to protect human or animal subjects;
* There is an immediate need to protect Federal funds or equipment or interests;
* Research activities should be suspended;
* Federal action is required to protect the interests of those involved in the research misconduct proceeding;
* There is a reasonable indication of possible civil or criminal law violation; or
* The Department of Health and Human Services may need to take appropriate steps to safeguard evidence and protect the rights of those involved.

UNMC will cooperate with ORI or other government agencies during oversight review or any subsequent administrative hearings or appeals. This includes provision of research records and evidence under the institution's control, custody, or possession and reasonable access to persons within its authority necessary to develop a complete record of relevant evidence.

===Other Considerations===
==== Respondent Admissions ====
Generally, all inquiries and investigations will be carried through to completion and all significant issues will be pursued diligently. For PHS-funded research, the Research Integrity Officer or designee must notify ORI in advance if there are plans to close a research misconduct proceeding at the assessment, inquiry, investigation, or appeal stage on the basis that respondent has admitted to committing research misconduct or a settlement with the respondent has been reached.

* A respondent’s admission must be made in writing and signed by the respondent and specify the falsification, fabrication, and/or plagiarism that occurred and which records were affected. The admission statement must meet all elements required for a finding of research misconduct and must be provided to ORI before the institution closes its research misconduct proceeding. UNMC must also provide a statement to ORI describing how it determined that the scope of misconduct was fully addressed by the admission and confirmed the respondent’s culpability.
:
==== Respondent Resignation/Withdrawal====
If the respondent terminates UNMC employment, resigns, or withdraws from school (in the case of a student) prior to completion of the inquiry or investigation, the inquiry or investigation will proceed. If the respondent refuses to participate in the proceedings, the investigation committee will use its best efforts to reach a conclusion concerning the allegations, noting in its report the respondent’s failure to cooperate and its effect on the committee's review of all the evidence. If a finding of research misconduct is made after a respondent terminates, resigns, or withdraws, UNMC will implement such corrective actions as may be applicable and possible given the termination, resignation, or withdrawal including, but not limited to, correcting the research record.
==== Restoration of Respondent's Reputation ====
If UNMC finds no research misconduct, and the funding agency concurs when required, the Research Integrity Officer will undertake reasonable efforts to restore the respondent's reputation after consulting with the respondent and receiving approval from the Institutional Deciding Official. Such actions could include, for example only, notifying those individuals aware of or involved in the investigation of the final outcome, publicizing the final outcome in any forum in which the allegation of research misconduct was previously publicized, and expunging all reference to the research misconduct allegation from the respondent's personnel file.
====Allegations Not Made in Good Faith====
If relevant, the Institutional Deciding Official will determine whether the complainant’s allegations of research misconduct were made in good faith. If an allegation was not made in good faith, the Institutional Deciding Official will determine if any administrative action should be taken against the complainant.
====Interim Administrative Actions====
UNMC officials shall take interim administrative actions, as appropriate, to protect Federal funds and ensure that the purposes of the Federal financial assistance are carried out.
===Record Retention===
The Research Integrity Officer or designee is delegated responsibility for preparing and maintaining all documentation gathered or generated during an inquiry and investigation including the institutional record and all sequestered evidence including physical objects (regardless of whether the evidence is part of the institutional record). All records shall be maintained in a secure manner for seven years after completion of the UNMC case or the completion of any federal proceeding involving the research misconduct allegation, whichever is later, unless custody has been transferred to the federal agency or the ORI or other federal agency advises otherwise in writing. If a person involved in a research misconduct proceeding for research that does not involve PHS or other federal funds whose data, documents, physical objects, or other materials were sequestered for purposes of the proceeding requests a return of such data, documents, physical objects, or other materials at the end of the proceeding, the Research Integrity Officer or designee will determine whether there are funding entity record retention requirements and whether substantially equivalent copies can be created and retained such that return is permissible. Federal funding and oversight agencies will be given access to the records upon request.

=== No Appeals ===
The decisions made by UNMC at assessment, inquiry, or investigation regarding an allegation of research misconduct are not subject to appeal by any complainant, respondent, or other individual.

==Additional information==
*Contact the [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer]<br />
*Contact the [mailto:jmeza@unmc.edu Research Integrity Officer]<br />

This page maintained by [mailto:mhurlocker@unmc.edu mh].

Inspections/Investigations by Third Parties

2026-09-21T15:56:45Z

Mhurlocker:

Compliance Hotline

2026-09-21T15:50:44Z

Mhurlocker:

Deadly Weapon

2026-09-21T15:48:46Z

Mhurlocker:

Policies and Procedures

2026-09-21T15:47:59Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|07/26/21
|07/09/24
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-03-alternative-worksite-policy.pdf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity] for all NU campuses, Executive Memorandum No. 40
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-05-recruitment-and-selection-policy.pdf HR-05, Recruitment and Selection Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/voluntary-fte-reduction-program.pdf Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|09/17/26
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|09/17/26
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|09/17/26
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|09/17/26
|-
|[[Export Control]]
|8005
|12/18/12
|07/21/23
|07/09/24
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|09/17/26
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|09/17/26
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|07/09/24
|07/09/24
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|09/17/26
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|09/17/26
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|09/17/26
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|07/21/23
|07/09/24
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|07/09/24
|07/09/24
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|09/17/26
|-
|[[Whistleblower]]
|8018
|04/11/19
|04/11/19
|07/09/24
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|09/17/26
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Artificial Intelligence (AI) Protections Policy

2026-09-10T16:27:18Z

Mhurlocker:

{{DISPLAYTITLE:UNMC AI Use Guidelines}}
{| class="wikitable"
|[[Human Resources]]
|
|[[Safety/Security]]
|
|[[Research Compliance]]
|
|[[Compliance]]
|
|[[Privacy/Information Security]]
|
|[[Business Operations]]
|
|[[Intellectual Property]]
|
|[[Faculty]]
|}
[[Compliance Program]] | [[Compliance Hotline]] | [[Inspections/Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | Electronic Digital Signatures and Records | [[Utilizing Generative AI|UNMC AI Use Guidelines]]| [https://wiki.unmc.edu/index.php/Artificial_Intelligence_(AI)_Protections_Policy Artificial Intelligence (AI) Protections Policy]

Effective Date: 06/2026

Revised Date: 06/2026

'''<big>Artificial Intelligence (AI) Protections Policy - IM #73</big>'''

'''1. PURPOSE'''

The purpose of this policy is to establish a framework for responsible and transformative use of artificial intelligence (AI) technologies to advance extraordinary patient care, operations, research, and education. AI is a strategic capability that can improve quality, safety, efficiency, and experience. At the same time, we have a duty to govern AI with rigor, transparency, fairness, and equity—protecting patients, workforce members, and enterprise. This policy establishes the protections, expectations, and institutional governance required to enable AI safely and confidently within Nebraska Medicine, UNMC, and the members of the Affiliated Covered Entity (ACE).

'''2. BASIS FOR POLICY'''

Nebraska Medicine/UNMC implements reasonable and appropriate controls for AI systems in alignment with National Institute of Standards and Technology (NIST) standards and guidance. NIST Special Publication 800-53, NIST CSF 2.0, and the HIPAA Privacy and Security Rules outline considerations for these controls.

'''FRAMEWORK REFERENCES'''

NIST SP 800-53 Rev 5: AC-2, AC-3, AU-2, AU-6, CM-2, CM-6, IR-4, IR-5, RA-3, RA-5, SI-3, SI-4, CP-2, CP-4

NIST CSF 2.0: PR.AC-1, PR.AC-4, PR.PT-1, DE.CM-7, PR.IP-1, PR.IP-3, RS.RP-1, RS.CO-1, ID.RA-1, ID.RA-3, PR.IP-2, DE.CM-4, RC.RP-1, RC.IM-1

HIPAA: 45 CFR 164.308, 164.312, 164.524, 164.526, 164.520

'''3. SCOPE'''

The Artificial Intelligence (AI) Protections Policy establishes the governance, protections, obligations, and expectations for the design, development, deployment, and use of AI systems across the enterprise. This policy supports innovation and improvement in care delivery, operations, research, and education while safeguarding privacy, equity, trust, and human oversight. This policy applies to all Artificial Intelligence (current and future) systems that are designed, developed, procured, deployed, operated, or used by Nebraska Medicine, UNMC, or on their behalf, regardless of whether such systems are used by members of the ACE workforce or by affiliated entities performing institutional functions.

For the purposes of this policy, “the institution” or “institutional” refers collectively to Nebraska Medicine, the University of Nebraska Medical Center (UNMC), and the members of the Affiliated Covered Entity (ACE), as applicable. This policy applies to internal AI models, third-party AI models, cloud-based AI models, and publicly available AI systems.

'''4. DEFINITIONS'''

* '''Affiliated Covered Entity (ACE):''' The legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current Nebraska Medical ACE members are Nebraska Medicine, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members.
* '''Black Box Model:''' An AI system whose internal logic, decision-making processes, or feature contributions are not readily interpretable or explainable to users or stakeholders.
* '''Hallucination (AI Hallucination):''' A phenomenon in which an AI system generates outputs that are factually incorrect, fabricated, or not grounded in source data while appearing plausible or authoritative.
* '''Interpretability:''' The degree to which a human can understand how an AI system produces its outputs, including the ability to trace inputs, logic, and contributing factors.
* '''Extractive AI:''' AI methods that identify, retrieve, or extract existing information from source data without generating new content (e.g., search, classification, summarization using source text).
* '''Retrieval-Augmented Generation (RAG):''' An AI architecture that enhances model outputs by retrieving relevant information from external knowledge sources (e.g., documents, databases) and incorporating that information into the response generation process.
* '''Workforce:''' All faculty, staff, volunteers, trainees, students, independent contractors, and other persons who perform services for, participate in programs of, or act on behalf of the institution, or whose activities are under the direct control of the institution, whether or not they are compensated by the institution.
* '''Developer/Designer:''' Workforce members who create AI systems (including model design, coding, prompt engineering, training, testing, and evaluation).
* '''Provisioner:''' Workforce members permitted by the developer to integrate AI into applications, tools, or workflows (e.g., connecting data sources, managing ingestion pipelines).
* '''Deployer/User:''' Workforce members who implement AI systems into production or use them in day-to-day work to generate content or support decision-making.
* '''Artificial Intelligence (AI):''' A machine-based system that performs tasks requiring human intelligence (e.g., pattern recognition, prediction, reasoning, and recommendation generation).
* '''Artificial Intelligence System (AI System):''' Any data system, software, model, application, or utility that operates in whole or in part using AI. This excludes rules based or deterministic systems that do not perform learning, inference, or probabilistic reasoning.
* '''Bias:''' A systematic tendency or error in judgment, data, or decision-making that can result in unfair, inaccurate, or inequitable outcomes.
* '''AI Bias:''' Bias that arises when an artificial intelligence system produces unfair, misleading, or harmful outcomes due to factors such as training data, algorithm design, system configuration, or human interpretation.
* '''Machine Learning (ML):''' A subset of AI where models learn patterns from data, improving performance over time with limited human intervention.
* '''Deep Learning:''' A subset of ML using multi-layer neural networks capable of processing complex, unstructured data.
* '''Generative AI:''' AI systems that generate original content (text, code, images, audio, etc.) based on learned patterns from training data.
* '''Large Language Model (LLM):''' A type of AI model trained on large-scale text data to interpret and generate natural language.
* '''Foundation Model:''' A large, pre-trained AI model trained on broad and diverse data that can be adapted to perform a wide range of downstream tasks.
* '''Model Drift:''' Deterioration in model performance due to changes in data, environment, or context over time.
* '''Intelligent Automation:''' The use of software systems to automate tasks or workflows, which may combine rules-based logic, robotic process automation, and artificial intelligence to execute actions with limited or no human intervention.
* '''Robotic Process Automation (RPA):''' A form of automation that uses software “bots” to execute predefined, rules-based tasks by interacting with applications and systems in the same manner as a human user.
* '''Intelligent Document Processing (IDP):''' An automation technology that applies artificial intelligence, including machine learning and natural language processing, to extract, classify, and validate information from unstructured or semi structured documents. Intelligent automation technologies, including RPA and IDP, are considered AI systems under this policy when they perform decision-making, data transformation, classification, or autonomous actions affecting institutional operations, data, or individuals.

'''5. POLICY'''

'''5.1 AI Governance Model'''

Institutional Leadership shall establish an AI Governance Model to oversee, coordinate, and monitor enterprise use of artificial intelligence across clinical, operational, research, and educational domains.

The AI Governance Model is designed to support consistent, risk-based, and accountable AI adoption while leveraging existing institutional decision-making structures.

'''5.1.1 Governance Functions'''

The AI Governance Model shall ensure the following functions are defined and continuously performed:

* Establish, maintain, and periodically review institutional AI policies, standards, and procedures.
* Provide guidance and recommendations on appropriate AI use across clinical, operational, research, and educational domains.
* Maintain an enterprise inventory of AI systems in use across the institution, including:
** Use-case and workflow classification (e.g., clinical decision support, documentation, monitoring, operations, revenue cycle, research, education).
** AI category or capability type (e.g., predictive, generative, automation, decision support).
** Promote clear ownership and accountability for AI systems, including:
*** IT or system owner
*** Operational or business owner
*** Responsible governance or decision-making body, where applicable.
** Promote a risk-based AI governance approach, with differentiated oversight expectations for lower- and higher-risk AI use cases, as defined in institutional standards or guidance.
** Provide visibility into AI-related risk assessment expectations and outcomes (e.g., privacy, compliance, cybersecurity, ethics, bias, equity).
** Monitor emerging risks, incidents, trends, or concerns related to AI systems and coordinate escalation to appropriate operational, compliance, security, or governance authorities when needed.
** Review aggregate reporting on AI-related incidents, concerns, or suspected policy violations to inform governance priorities and policy updates.
** Support efficient adoption of lower-risk AI use cases through streamlined governance pathways, as defined in institutional standards or guidance.

'''5.1.2 Governance Structure and Participation'''

The AI Governance Model may be supported by one or more coordinating bodies, councils, or working groups as designated by Institutional Leadership. These bodies serve an advisory and coordination role and do not independently approve, authorize, or deploy individual AI systems.

Clinical validation, patient safety determinations, and clinical decision-making authority remain within established clinical governance structures.

Membership and participation may include representatives from:

* Data, Analytics & AI Engineering
* Clinical Informatics
* Clinical Operations
* Information Security
* Privacy
* Enterprise Risk Management
* Compliance and Legal Affairs
* Platform/DevOps Engineering
* Workforce Training and Education
* Research and Academic Governance
* Library and Information Services
* Marketing and Communications

Standing clinician representation shall be incorporated to ensure clinical workflow, safety, and care delivery perspectives are included.

Ad hoc subject-matter experts may participate as needed based on AI use cases, domains, or risk profiles.

'''5.2 Workforce Responsibilities'''

'''5.2.1 Developers/Designers:'''

* Ensure data quality and lawful data use.
* Document model purpose, performance characteristics, limitations, and appropriate use context, including known risks and conditions under which the model should not be relied upon.
* Proactively assesses potential failures and mitigation strategies.
* Evaluate bias and equity impacts prior to deployment.

'''5.2.2 Provisioners:'''

* Ensure accurate and secure data flows into AI systems.
* Ensure systems are integrated only with approved data sources.
* Ensure privacy, security, and governance controls remain intact.

'''5.2.3 Deployers/Users:'''

* Understand the limitations of the AI system.
* Review AI-generated outputs for accuracy, appropriateness, and fairness.
* Do not rely on AI output as the sole basis for clinical or operational decision-making.
* Escalate concerns or unsafe results to the appropriate governance authority.

Clinical validation, determination of clinical accuracy, and assessment of patient safety impact are performed through established clinical governance processes and are not the responsibility of individual developers or end users acting alone.

'''5.3 Branding and Institutional Identity'''

Workforce members may not use AI systems to generate, replicate, modify, or approximate official Nebraska Medicine or University of Nebraska Medical Center (UNMC) logos, emblems, seals, trademarks, or other protected brand assets. All use of official logos and branding elements must continue to follow established Marketing and Brand Governance processes, including formal logo requests and approvals.

'''6. PRINCIPLES AND PRACTICAL REQUIREMENTS'''

The institution’s approach to AI is guided by principles. Each principle includes required practices.

'''6.1 Principle: AI must protect privacy, confidentiality, and security.'''

* 6.1.1 No Protected Health Information (PHI), confidential operational information, proprietary information, or internal restricted data may be entered into any public or unapproved AI application.
* 6.1.2 Access to AI systems that process institutional data must comply with institutional account, device, and security requirements.
** 6.1.2.a Nebraska Medicine: Use of personal email accounts, personal phone numbers, personal cloud accounts, or personal devices to access or process institutional data through AI systems is prohibited unless specifically authorized.
** 6.1.2.b University of Nebraska Medical Center (UNMC): Use of personal devices to access or process institutional data through AI systems is permitted for UNMC workforce members and students when accessed via approved UNMC accounts and in compliance with institutional security, privacy, and data protection requirements.
* 6.1.3 Any AI system used with institutional data must meet institutional security standards and (where applicable) HIPAA requirements.
* 6.1.4 Vendors must not use or share institutional data for purposes beyond what is contractually approved and must be under appropriate legal agreements (e.g., BAA, DUA, MSA/SOW) prior to receiving data access.

'''6.2 Principle: AI must preserve human accountability.'''

A qualified human (“learner intermediary”) must remain responsible for interpreting AI outputs and making final decisions.

* 6.2.1 AI may not act as the final decision-maker in place of clinicians, operational leaders, and other professionals.
* 6.2.2 Workforce members must review AI output before acting on it.
* 6.2.3 Patients have the right to request human review of decisions influenced by AI. Any documentation or records generated in connection with such requests are subject to applicable institutional record-retention and privacy requirements.
* 6.2.4 AI systems must include human oversight appropriate to their level of risk. Oversight mechanisms may be adjusted for use cases based on risk classification, system performance, and validation; however, a qualified human remains accountable for outcomes and decisions influenced by AI.

'''6.3 Principle: AI must be safe, accurate, reliable, fair, and monitored.'''

* 6.3.1 AI systems must be designed, deployed, and used in a manner that prioritizes safety and minimizes the risk of harm to patients, workforce members, and operations, consistent with the institution’s Zero Harm commitment.
* 6.3.2 Developers must evaluate model performance prior to deployment.
* 6.3.3 Red-teaming, scenario testing, or stress testing must be conducted for models used in sensitive contexts.
* 6.3.4 Model performance must be re-evaluated periodically to detect drift, degradation, and bias.
* 6.3.5 Workforce users must escalate concerns or anomalies through appropriate institutional reporting mechanisms, which may include Information Security, Privacy, Clinical Safety, or the AI Oversight Committee, depending on the nature of the issue.
* 6.3.6 AI systems must be monitored over time to ensure they are fit for their intended use. Evaluation criteria and performance expectations must be appropriate to the use case, risk level, and context of use.

'''6.4 Principle: AI use must be transparent.'''

* '''6.4.1 Patient-Facing AI Disclosure''': When AI is used in patient-facing contexts, the involvement of AI must be disclosed.
** '''6.4.1.a Definition of Patient-Facing AI''': For purposes of this policy, patient-facing refers to AI-generated content, recommendations, or interactions that are presented directly to a patient without substantive clinician modification and that may influence a patient’s understanding, decisions, or actions related to their care.
* '''6.4.2 Clinician-Mediated Content''': Use of AI to assist clinicians in drafting, summarizing, or documenting content (e.g., ambient clinical documentation, draft patient instructions, or draft patient portal messages) does not require disclosure when the final content is reviewed, edited, and approved by a clinician and presented as clinician-authored.
* '''6.4.3 Written Disclosure Mechanisms''': Written disclosure of AI usage may be included within institutional Notice of Privacy Practices or similar patient-facing materials, as appropriate.
* '''6.4.4 External Use Attribution''': When AI-generated content is used externally (e.g., presentations, media, publications), attribution to the system used must be clearly noted.
* '''6.4.5 Transparency for Decision-Support Outputs''': When AI systems generate outputs intended to inform clinical, operational, research, or academic decision-making, the system must provide sufficient transparency to allow users to evaluate and validate the output, including access to source references, citations, or supporting context where technically feasible.
* '''6.4.6 Non-Authoritative Presentation of AI Outputs''': For AI systems used in decision-support contexts, outputs must not be presented as authoritative or definitive without appropriate citations, source references, or explanatory context to support human review and judgment.

'''6.5 Principle: AI use must be aligned to mission and values.'''

* 6.5.1 AI must not be used to generate or disseminate unlawful, fraudulent, harmful, plagiarized, inappropriate, or discriminatory content.
* 6.5.2 AI must not be used to create misinformation or content that misrepresents the institution.
* 6.5.3 AI must be designed, deployed, and used in ways that reflect the institution’s values and ethical standards.

'''6.6 Principle: AI must be accessible and inclusive.'''

* 6.6.1 AI systems, tools, interfaces, and AI-generated outputs must comply with applicable accessibility requirements, including the Americans with Disabilities Act (ADA) and institutional digital accessibility standards.
* 6.6.2 AI systems that are patient-facing, learner-facing, workforce-facing, or used in clinical, educational, or operational workflows must be designed and configured to support equitable access for individuals with disabilities.
* 6.6.3 Accessibility considerations must be included as part of AI system intake and risk assessment, and accessibility risks must be mitigated prior to deployment.

'''6.7 Governance of Principles'''

* 6.7.1 Changes to the Principles and Practical Requirements defined in Section 6 require review and approval by the AI Oversight Committee and must follow established institutional policy governance and approval processes.
* 6.7.2 Material changes that alter risk posture, regulatory obligations, or clinical or operational safety requirements may require additional review or approval by executive leadership, Legal Affairs, Compliance, or other governance bodies, as appropriate.
* 6.7.3 AI Embedded in Approved Enterprise Platforms: AI capabilities embedded within approved enterprise platforms (e.g., EHR, analytics, productivity, or operational systems) are subject to institutional AI governance. Initial review and approval may leverage existing platform, clinical, or operational governance processes. Introduction of new AI models or capabilities, material changes to intended use, data sources, autonomy, or risk profile may require additional review and approval under this policy.

'''7. ENFORCEMENT, TRAINING, AND REPORTING'''

'''7.1 Training Requirements'''

* 7.1.1 Workforce members may be required to complete assigned AI education prior to receiving access to AI systems.
* 7.1.2 Ongoing training, refreshers, and/or attestations may be required as systems evolve.

'''7.2 Reporting'''

* 7.2.1 Any suspected misuse, unsafe output, adverse event, or potential violation related to AI systems must be reported promptly through appropriate institutional reporting mechanisms, which may include Information Security reporting channels and/or the Safety Event Reporting System (SOS – RL Solutions), as applicable.
* 7.2.2 Reported AI-related concerns or incidents will be reviewed and triaged to the appropriate oversight area based on the nature of the issue, which may include Information Security, Privacy, Compliance, Ethics, Clinical Safety, Patient Safety, Research Integrity, or other relevant governance bodies.
* 7.2.3 Workforce members must not attempt to conceal AI-related incidents, output anomalies, or errors.

'''7.3 Enforcement'''

* 7.3.1 Violations of this policy may result in disciplinary action consistent with institutional HR policy.
* 7.3.2 Significant violations (e.g., privacy breach, safety risk, intentional misuse) will be escalated to Executive Leadership, Compliance, Legal Affairs, and/or Information Security as appropriate.

'''7.3.3 Response to Escalated AI Concerns'''

* Upon escalation of an AI-related concern, incident, or identified risk, the AI Oversight Committee will review the issue and determine an appropriate course of action based on severity, risk, and impact. Actions may include, but are not limited to:
** Requesting additional evaluation, validation, or monitoring
** Requiring remediation or modification of the AI system or workflow
** Temporarily suspending or restricting use of the AI system
** Referring the issue to appropriate governance bodies (e.g., Information Security, Privacy, Compliance, Patient Safety, or Clinical Governance)
** Recommending continuation, modification, or retirement of the AI system to the appropriate responsible authority
** Final decisions and enforcement actions are executed by the responsible operational, clinical, compliance, or executive governance bodies.

Escalated issues involving patient safety, regulatory compliance, or legal risk will be coordinated with executive leadership and appropriate institutional authorities.

Information Security will periodically review and update this policy as new technologies and risks are identified.

'''STAFF ACCOUNTABILITY'''

Chief Information Security Officer

Vice President, Information Technology

'''Department Approval'''

Signed: Lisa Bazis

Title: Chief Information Security Officer

'''Administrative Approval'''

Signed: Keith Rivera

==== '''Title: Vice President, Information Technology''' ====

This page maintained by [Mailto:mhurlocker@unmc.edu mh].

UNMC AI Use Guidelines

2026-09-10T16:23:42Z

Mhurlocker: /* Guidelines */

Artificial Intelligence (AI) Protections Policy

2026-09-10T16:23:04Z

Mhurlocker:

{{DISPLAYTITLE:UNMC AI Use Guidelines}}
{| class="wikitable"
|[[Human Resources]]
|
|[[Safety/Security]]
|
|[[Research Compliance]]
|
|[[Compliance]]
|
|[[Privacy/Information Security]]
|
|[[Business Operations]]
|
|[[Intellectual Property]]
|
|[[Faculty]]
|}
[[Compliance Program]] | [[Compliance Hotline]] | [[Inspections/Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | Electronic Digital Signatures and Records | [[Utilizing Generative AI|UNMC AI Use Guidelines]]| [https://wiki.unmc.edu/index.php?title=Artificial_Intelligence_(AI)_Protections_Policy&action=edit Artificial Intelligence (AI) Protections Policy]

Effective Date: 06/2026

Revised Date: 06/2026

'''<big>Artificial Intelligence (AI) Protections Policy - IM #73</big>'''

'''1. PURPOSE'''

The purpose of this policy is to establish a framework for responsible and transformative use of artificial intelligence (AI) technologies to advance extraordinary patient care, operations, research, and education. AI is a strategic capability that can improve quality, safety, efficiency, and experience. At the same time, we have a duty to govern AI with rigor, transparency, fairness, and equity—protecting patients, workforce members, and enterprise. This policy establishes the protections, expectations, and institutional governance required to enable AI safely and confidently within Nebraska Medicine, UNMC, and the members of the Affiliated Covered Entity (ACE).

'''2. BASIS FOR POLICY'''

Nebraska Medicine/UNMC implements reasonable and appropriate controls for AI systems in alignment with National Institute of Standards and Technology (NIST) standards and guidance. NIST Special Publication 800-53, NIST CSF 2.0, and the HIPAA Privacy and Security Rules outline considerations for these controls.

'''FRAMEWORK REFERENCES'''

NIST SP 800-53 Rev 5: AC-2, AC-3, AU-2, AU-6, CM-2, CM-6, IR-4, IR-5, RA-3, RA-5, SI-3, SI-4, CP-2, CP-4

NIST CSF 2.0: PR.AC-1, PR.AC-4, PR.PT-1, DE.CM-7, PR.IP-1, PR.IP-3, RS.RP-1, RS.CO-1, ID.RA-1, ID.RA-3, PR.IP-2, DE.CM-4, RC.RP-1, RC.IM-1

HIPAA: 45 CFR 164.308, 164.312, 164.524, 164.526, 164.520

'''3. SCOPE'''

The Artificial Intelligence (AI) Protections Policy establishes the governance, protections, obligations, and expectations for the design, development, deployment, and use of AI systems across the enterprise. This policy supports innovation and improvement in care delivery, operations, research, and education while safeguarding privacy, equity, trust, and human oversight. This policy applies to all Artificial Intelligence (current and future) systems that are designed, developed, procured, deployed, operated, or used by Nebraska Medicine, UNMC, or on their behalf, regardless of whether such systems are used by members of the ACE workforce or by affiliated entities performing institutional functions.

For the purposes of this policy, “the institution” or “institutional” refers collectively to Nebraska Medicine, the University of Nebraska Medical Center (UNMC), and the members of the Affiliated Covered Entity (ACE), as applicable. This policy applies to internal AI models, third-party AI models, cloud-based AI models, and publicly available AI systems.

'''4. DEFINITIONS'''

* '''Affiliated Covered Entity (ACE):''' The legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current Nebraska Medical ACE members are Nebraska Medicine, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members.
* '''Black Box Model:''' An AI system whose internal logic, decision-making processes, or feature contributions are not readily interpretable or explainable to users or stakeholders.
* '''Hallucination (AI Hallucination):''' A phenomenon in which an AI system generates outputs that are factually incorrect, fabricated, or not grounded in source data while appearing plausible or authoritative.
* '''Interpretability:''' The degree to which a human can understand how an AI system produces its outputs, including the ability to trace inputs, logic, and contributing factors.
* '''Extractive AI:''' AI methods that identify, retrieve, or extract existing information from source data without generating new content (e.g., search, classification, summarization using source text).
* '''Retrieval-Augmented Generation (RAG):''' An AI architecture that enhances model outputs by retrieving relevant information from external knowledge sources (e.g., documents, databases) and incorporating that information into the response generation process.
* '''Workforce:''' All faculty, staff, volunteers, trainees, students, independent contractors, and other persons who perform services for, participate in programs of, or act on behalf of the institution, or whose activities are under the direct control of the institution, whether or not they are compensated by the institution.
* '''Developer/Designer:''' Workforce members who create AI systems (including model design, coding, prompt engineering, training, testing, and evaluation).
* '''Provisioner:''' Workforce members permitted by the developer to integrate AI into applications, tools, or workflows (e.g., connecting data sources, managing ingestion pipelines).
* '''Deployer/User:''' Workforce members who implement AI systems into production or use them in day-to-day work to generate content or support decision-making.
* '''Artificial Intelligence (AI):''' A machine-based system that performs tasks requiring human intelligence (e.g., pattern recognition, prediction, reasoning, and recommendation generation).
* '''Artificial Intelligence System (AI System):''' Any data system, software, model, application, or utility that operates in whole or in part using AI. This excludes rules based or deterministic systems that do not perform learning, inference, or probabilistic reasoning.
* '''Bias:''' A systematic tendency or error in judgment, data, or decision-making that can result in unfair, inaccurate, or inequitable outcomes.
* '''AI Bias:''' Bias that arises when an artificial intelligence system produces unfair, misleading, or harmful outcomes due to factors such as training data, algorithm design, system configuration, or human interpretation.
* '''Machine Learning (ML):''' A subset of AI where models learn patterns from data, improving performance over time with limited human intervention.
* '''Deep Learning:''' A subset of ML using multi-layer neural networks capable of processing complex, unstructured data.
* '''Generative AI:''' AI systems that generate original content (text, code, images, audio, etc.) based on learned patterns from training data.
* '''Large Language Model (LLM):''' A type of AI model trained on large-scale text data to interpret and generate natural language.
* '''Foundation Model:''' A large, pre-trained AI model trained on broad and diverse data that can be adapted to perform a wide range of downstream tasks.
* '''Model Drift:''' Deterioration in model performance due to changes in data, environment, or context over time.
* '''Intelligent Automation:''' The use of software systems to automate tasks or workflows, which may combine rules-based logic, robotic process automation, and artificial intelligence to execute actions with limited or no human intervention.
* '''Robotic Process Automation (RPA):''' A form of automation that uses software “bots” to execute predefined, rules-based tasks by interacting with applications and systems in the same manner as a human user.
* '''Intelligent Document Processing (IDP):''' An automation technology that applies artificial intelligence, including machine learning and natural language processing, to extract, classify, and validate information from unstructured or semi structured documents. Intelligent automation technologies, including RPA and IDP, are considered AI systems under this policy when they perform decision-making, data transformation, classification, or autonomous actions affecting institutional operations, data, or individuals.

'''5. POLICY'''

'''5.1 AI Governance Model'''

Institutional Leadership shall establish an AI Governance Model to oversee, coordinate, and monitor enterprise use of artificial intelligence across clinical, operational, research, and educational domains.

The AI Governance Model is designed to support consistent, risk-based, and accountable AI adoption while leveraging existing institutional decision-making structures.

'''5.1.1 Governance Functions'''

The AI Governance Model shall ensure the following functions are defined and continuously performed:

* Establish, maintain, and periodically review institutional AI policies, standards, and procedures.
* Provide guidance and recommendations on appropriate AI use across clinical, operational, research, and educational domains.
* Maintain an enterprise inventory of AI systems in use across the institution, including:
** Use-case and workflow classification (e.g., clinical decision support, documentation, monitoring, operations, revenue cycle, research, education).
** AI category or capability type (e.g., predictive, generative, automation, decision support).
** Promote clear ownership and accountability for AI systems, including:
*** IT or system owner
*** Operational or business owner
*** Responsible governance or decision-making body, where applicable.
** Promote a risk-based AI governance approach, with differentiated oversight expectations for lower- and higher-risk AI use cases, as defined in institutional standards or guidance.
** Provide visibility into AI-related risk assessment expectations and outcomes (e.g., privacy, compliance, cybersecurity, ethics, bias, equity).
** Monitor emerging risks, incidents, trends, or concerns related to AI systems and coordinate escalation to appropriate operational, compliance, security, or governance authorities when needed.
** Review aggregate reporting on AI-related incidents, concerns, or suspected policy violations to inform governance priorities and policy updates.
** Support efficient adoption of lower-risk AI use cases through streamlined governance pathways, as defined in institutional standards or guidance.

'''5.1.2 Governance Structure and Participation'''

The AI Governance Model may be supported by one or more coordinating bodies, councils, or working groups as designated by Institutional Leadership. These bodies serve an advisory and coordination role and do not independently approve, authorize, or deploy individual AI systems.

Clinical validation, patient safety determinations, and clinical decision-making authority remain within established clinical governance structures.

Membership and participation may include representatives from:

* Data, Analytics & AI Engineering
* Clinical Informatics
* Clinical Operations
* Information Security
* Privacy
* Enterprise Risk Management
* Compliance and Legal Affairs
* Platform/DevOps Engineering
* Workforce Training and Education
* Research and Academic Governance
* Library and Information Services
* Marketing and Communications

Standing clinician representation shall be incorporated to ensure clinical workflow, safety, and care delivery perspectives are included.

Ad hoc subject-matter experts may participate as needed based on AI use cases, domains, or risk profiles.

'''5.2 Workforce Responsibilities'''

'''5.2.1 Developers/Designers:'''

* Ensure data quality and lawful data use.
* Document model purpose, performance characteristics, limitations, and appropriate use context, including known risks and conditions under which the model should not be relied upon.
* Proactively assesses potential failures and mitigation strategies.
* Evaluate bias and equity impacts prior to deployment.

'''5.2.2 Provisioners:'''

* Ensure accurate and secure data flows into AI systems.
* Ensure systems are integrated only with approved data sources.
* Ensure privacy, security, and governance controls remain intact.

'''5.2.3 Deployers/Users:'''

* Understand the limitations of the AI system.
* Review AI-generated outputs for accuracy, appropriateness, and fairness.
* Do not rely on AI output as the sole basis for clinical or operational decision-making.
* Escalate concerns or unsafe results to the appropriate governance authority.

Clinical validation, determination of clinical accuracy, and assessment of patient safety impact are performed through established clinical governance processes and are not the responsibility of individual developers or end users acting alone.

'''5.3 Branding and Institutional Identity'''

Workforce members may not use AI systems to generate, replicate, modify, or approximate official Nebraska Medicine or University of Nebraska Medical Center (UNMC) logos, emblems, seals, trademarks, or other protected brand assets. All use of official logos and branding elements must continue to follow established Marketing and Brand Governance processes, including formal logo requests and approvals.

'''6. PRINCIPLES AND PRACTICAL REQUIREMENTS'''

The institution’s approach to AI is guided by principles. Each principle includes required practices.

'''6.1 Principle: AI must protect privacy, confidentiality, and security.'''

* 6.1.1 No Protected Health Information (PHI), confidential operational information, proprietary information, or internal restricted data may be entered into any public or unapproved AI application.
* 6.1.2 Access to AI systems that process institutional data must comply with institutional account, device, and security requirements.
** 6.1.2.a Nebraska Medicine: Use of personal email accounts, personal phone numbers, personal cloud accounts, or personal devices to access or process institutional data through AI systems is prohibited unless specifically authorized.
** 6.1.2.b University of Nebraska Medical Center (UNMC): Use of personal devices to access or process institutional data through AI systems is permitted for UNMC workforce members and students when accessed via approved UNMC accounts and in compliance with institutional security, privacy, and data protection requirements.
* 6.1.3 Any AI system used with institutional data must meet institutional security standards and (where applicable) HIPAA requirements.
* 6.1.4 Vendors must not use or share institutional data for purposes beyond what is contractually approved and must be under appropriate legal agreements (e.g., BAA, DUA, MSA/SOW) prior to receiving data access.

'''6.2 Principle: AI must preserve human accountability.'''

A qualified human (“learner intermediary”) must remain responsible for interpreting AI outputs and making final decisions.

* 6.2.1 AI may not act as the final decision-maker in place of clinicians, operational leaders, and other professionals.
* 6.2.2 Workforce members must review AI output before acting on it.
* 6.2.3 Patients have the right to request human review of decisions influenced by AI. Any documentation or records generated in connection with such requests are subject to applicable institutional record-retention and privacy requirements.
* 6.2.4 AI systems must include human oversight appropriate to their level of risk. Oversight mechanisms may be adjusted for use cases based on risk classification, system performance, and validation; however, a qualified human remains accountable for outcomes and decisions influenced by AI.

'''6.3 Principle: AI must be safe, accurate, reliable, fair, and monitored.'''

* 6.3.1 AI systems must be designed, deployed, and used in a manner that prioritizes safety and minimizes the risk of harm to patients, workforce members, and operations, consistent with the institution’s Zero Harm commitment.
* 6.3.2 Developers must evaluate model performance prior to deployment.
* 6.3.3 Red-teaming, scenario testing, or stress testing must be conducted for models used in sensitive contexts.
* 6.3.4 Model performance must be re-evaluated periodically to detect drift, degradation, and bias.
* 6.3.5 Workforce users must escalate concerns or anomalies through appropriate institutional reporting mechanisms, which may include Information Security, Privacy, Clinical Safety, or the AI Oversight Committee, depending on the nature of the issue.
* 6.3.6 AI systems must be monitored over time to ensure they are fit for their intended use. Evaluation criteria and performance expectations must be appropriate to the use case, risk level, and context of use.

'''6.4 Principle: AI use must be transparent.'''

* '''6.4.1 Patient-Facing AI Disclosure''': When AI is used in patient-facing contexts, the involvement of AI must be disclosed.
** '''6.4.1.a Definition of Patient-Facing AI''': For purposes of this policy, patient-facing refers to AI-generated content, recommendations, or interactions that are presented directly to a patient without substantive clinician modification and that may influence a patient’s understanding, decisions, or actions related to their care.
* '''6.4.2 Clinician-Mediated Content''': Use of AI to assist clinicians in drafting, summarizing, or documenting content (e.g., ambient clinical documentation, draft patient instructions, or draft patient portal messages) does not require disclosure when the final content is reviewed, edited, and approved by a clinician and presented as clinician-authored.
* '''6.4.3 Written Disclosure Mechanisms''': Written disclosure of AI usage may be included within institutional Notice of Privacy Practices or similar patient-facing materials, as appropriate.
* '''6.4.4 External Use Attribution''': When AI-generated content is used externally (e.g., presentations, media, publications), attribution to the system used must be clearly noted.
* '''6.4.5 Transparency for Decision-Support Outputs''': When AI systems generate outputs intended to inform clinical, operational, research, or academic decision-making, the system must provide sufficient transparency to allow users to evaluate and validate the output, including access to source references, citations, or supporting context where technically feasible.
* '''6.4.6 Non-Authoritative Presentation of AI Outputs''': For AI systems used in decision-support contexts, outputs must not be presented as authoritative or definitive without appropriate citations, source references, or explanatory context to support human review and judgment.

'''6.5 Principle: AI use must be aligned to mission and values.'''

* 6.5.1 AI must not be used to generate or disseminate unlawful, fraudulent, harmful, plagiarized, inappropriate, or discriminatory content.
* 6.5.2 AI must not be used to create misinformation or content that misrepresents the institution.
* 6.5.3 AI must be designed, deployed, and used in ways that reflect the institution’s values and ethical standards.

'''6.6 Principle: AI must be accessible and inclusive.'''

* 6.6.1 AI systems, tools, interfaces, and AI-generated outputs must comply with applicable accessibility requirements, including the Americans with Disabilities Act (ADA) and institutional digital accessibility standards.
* 6.6.2 AI systems that are patient-facing, learner-facing, workforce-facing, or used in clinical, educational, or operational workflows must be designed and configured to support equitable access for individuals with disabilities.
* 6.6.3 Accessibility considerations must be included as part of AI system intake and risk assessment, and accessibility risks must be mitigated prior to deployment.

'''6.7 Governance of Principles'''

* 6.7.1 Changes to the Principles and Practical Requirements defined in Section 6 require review and approval by the AI Oversight Committee and must follow established institutional policy governance and approval processes.
* 6.7.2 Material changes that alter risk posture, regulatory obligations, or clinical or operational safety requirements may require additional review or approval by executive leadership, Legal Affairs, Compliance, or other governance bodies, as appropriate.
* 6.7.3 AI Embedded in Approved Enterprise Platforms: AI capabilities embedded within approved enterprise platforms (e.g., EHR, analytics, productivity, or operational systems) are subject to institutional AI governance. Initial review and approval may leverage existing platform, clinical, or operational governance processes. Introduction of new AI models or capabilities, material changes to intended use, data sources, autonomy, or risk profile may require additional review and approval under this policy.

'''7. ENFORCEMENT, TRAINING, AND REPORTING'''

'''7.1 Training Requirements'''

* 7.1.1 Workforce members may be required to complete assigned AI education prior to receiving access to AI systems.
* 7.1.2 Ongoing training, refreshers, and/or attestations may be required as systems evolve.

'''7.2 Reporting'''

* 7.2.1 Any suspected misuse, unsafe output, adverse event, or potential violation related to AI systems must be reported promptly through appropriate institutional reporting mechanisms, which may include Information Security reporting channels and/or the Safety Event Reporting System (SOS – RL Solutions), as applicable.
* 7.2.2 Reported AI-related concerns or incidents will be reviewed and triaged to the appropriate oversight area based on the nature of the issue, which may include Information Security, Privacy, Compliance, Ethics, Clinical Safety, Patient Safety, Research Integrity, or other relevant governance bodies.
* 7.2.3 Workforce members must not attempt to conceal AI-related incidents, output anomalies, or errors.

'''7.3 Enforcement'''

* 7.3.1 Violations of this policy may result in disciplinary action consistent with institutional HR policy.
* 7.3.2 Significant violations (e.g., privacy breach, safety risk, intentional misuse) will be escalated to Executive Leadership, Compliance, Legal Affairs, and/or Information Security as appropriate.

'''7.3.3 Response to Escalated AI Concerns'''

* Upon escalation of an AI-related concern, incident, or identified risk, the AI Oversight Committee will review the issue and determine an appropriate course of action based on severity, risk, and impact. Actions may include, but are not limited to:
** Requesting additional evaluation, validation, or monitoring
** Requiring remediation or modification of the AI system or workflow
** Temporarily suspending or restricting use of the AI system
** Referring the issue to appropriate governance bodies (e.g., Information Security, Privacy, Compliance, Patient Safety, or Clinical Governance)
** Recommending continuation, modification, or retirement of the AI system to the appropriate responsible authority
** Final decisions and enforcement actions are executed by the responsible operational, clinical, compliance, or executive governance bodies.

Escalated issues involving patient safety, regulatory compliance, or legal risk will be coordinated with executive leadership and appropriate institutional authorities.

Information Security will periodically review and update this policy as new technologies and risks are identified.

'''STAFF ACCOUNTABILITY'''

Chief Information Security Officer

Vice President, Information Technology

'''Department Approval'''

Signed: Lisa Bazis

Title: Chief Information Security Officer

'''Administrative Approval'''

Signed: Keith Rivera

==== '''Title: Vice President, Information Technology''' ====

This page maintained by [Mailto:mhurlocker@unmc.edu mh].

Artificial Intelligence (AI) Protections Policy

2026-09-09T20:11:53Z

Mhurlocker:

{{DISPLAYTITLE:UNMC AI Use Guidelines}}
{| class="wikitable"
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|[[Compliance]]
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[[Compliance Program]] | [[Compliance Hotline]] | [[Inspections/Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | Electronic Digital Signatures and Records | [[Utilizing Generative AI|UNMC AI Use Guidelines]]| [https://wiki.unmc.edu/index.php?title=Artificial_Intelligence_(AI)_Protections_Policy&action=edit Artificial Intelligence (AI) Protections Policy]

Effective Date: 06/2026

Revised Date: 06/2026

'''<big>Artificial Intelligence (AI) Protections Policy - IM #73</big>'''

'''1. PURPOSE'''

The purpose of this policy is to establish a framework for responsible and transformative use of artificial intelligence (AI) technologies to advance extraordinary patient care, operations, research, and education. AI is a strategic capability that can improve quality, safety, efficiency, and experience. At the same time, we have a duty to govern AI with rigor, transparency, fairness, and equity—protecting patients, workforce members, and enterprise. This policy establishes the protections, expectations, and institutional governance required to enable AI safely and confidently within Nebraska Medicine, UNMC, and the members of the Affiliated Covered Entity (ACE).

'''2. BASIS FOR POLICY'''

Nebraska Medicine/UNMC implements reasonable and appropriate controls for AI systems in alignment with National Institute of Standards and Technology (NIST) standards and guidance. NIST Special Publication 800-53, NIST CSF 2.0, and the HIPAA Privacy and Security Rules outline considerations for these controls.

'''FRAMEWORK REFERENCES'''

NIST SP 800-53 Rev 5: AC-2, AC-3, AU-2, AU-6, CM-2, CM-6, IR-4, IR-5, RA-3, RA-5, SI-3, SI-4, CP-2, CP-4

NIST CSF 2.0: PR.AC-1, PR.AC-4, PR.PT-1, DE.CM-7, PR.IP-1, PR.IP-3, RS.RP-1, RS.CO-1, ID.RA-1, ID.RA-3, PR.IP-2, DE.CM-4, RC.RP-1, RC.IM-1

HIPAA: 45 CFR 164.308, 164.312, 164.524, 164.526, 164.520

'''3. SCOPE'''

The Artificial Intelligence (AI) Protections Policy establishes the governance, protections, obligations, and expectations for the design, development, deployment, and use of AI systems across the enterprise. This policy supports innovation and improvement in care delivery, operations, research, and education while safeguarding privacy, equity, trust, and human oversight. This policy applies to all Artificial Intelligence (current and future) systems that are designed, developed, procured, deployed, operated, or used by Nebraska Medicine, UNMC, or on their behalf, regardless of whether such systems are used by members of the ACE workforce or by affiliated entities performing institutional functions.

For the purposes of this policy, “the institution” or “institutional” refers collectively to Nebraska Medicine, the University of Nebraska Medical Center (UNMC), and the members of the Affiliated Covered Entity (ACE), as applicable. This policy applies to internal AI models, third-party AI models, cloud-based AI models, and publicly available AI systems.

'''4. DEFINITIONS'''

* '''Affiliated Covered Entity (ACE):''' The legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current Nebraska Medical ACE members are Nebraska Medicine, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members.
* '''Black Box Model:''' An AI system whose internal logic, decision-making processes, or feature contributions are not readily interpretable or explainable to users or stakeholders.
* '''Hallucination (AI Hallucination):''' A phenomenon in which an AI system generates outputs that are factually incorrect, fabricated, or not grounded in source data while appearing plausible or authoritative.
* '''Interpretability:''' The degree to which a human can understand how an AI system produces its outputs, including the ability to trace inputs, logic, and contributing factors.
* '''Extractive AI:''' AI methods that identify, retrieve, or extract existing information from source data without generating new content (e.g., search, classification, summarization using source text).
* '''Retrieval-Augmented Generation (RAG):''' An AI architecture that enhances model outputs by retrieving relevant information from external knowledge sources (e.g., documents, databases) and incorporating that information into the response generation process.
* '''Workforce:''' All faculty, staff, volunteers, trainees, students, independent contractors, and other persons who perform services for, participate in programs of, or act on behalf of the institution, or whose activities are under the direct control of the institution, whether or not they are compensated by the institution.
* '''Developer/Designer:''' Workforce members who create AI systems (including model design, coding, prompt engineering, training, testing, and evaluation).
* '''Provisioner:''' Workforce members permitted by the developer to integrate AI into applications, tools, or workflows (e.g., connecting data sources, managing ingestion pipelines).
* '''Deployer/User:''' Workforce members who implement AI systems into production or use them in day-to-day work to generate content or support decision-making.
* '''Artificial Intelligence (AI):''' A machine-based system that performs tasks requiring human intelligence (e.g., pattern recognition, prediction, reasoning, and recommendation generation).
* '''Artificial Intelligence System (AI System):''' Any data system, software, model, application, or utility that operates in whole or in part using AI. This excludes rules based or deterministic systems that do not perform learning, inference, or probabilistic reasoning.
* '''Bias:''' A systematic tendency or error in judgment, data, or decision-making that can result in unfair, inaccurate, or inequitable outcomes.
* '''AI Bias:''' Bias that arises when an artificial intelligence system produces unfair, misleading, or harmful outcomes due to factors such as training data, algorithm design, system configuration, or human interpretation.
* '''Machine Learning (ML):''' A subset of AI where models learn patterns from data, improving performance over time with limited human intervention.
* '''Deep Learning:''' A subset of ML using multi-layer neural networks capable of processing complex, unstructured data.
* '''Generative AI:''' AI systems that generate original content (text, code, images, audio, etc.) based on learned patterns from training data.
* '''Large Language Model (LLM):''' A type of AI model trained on large-scale text data to interpret and generate natural language.
* '''Foundation Model:''' A large, pre-trained AI model trained on broad and diverse data that can be adapted to perform a wide range of downstream tasks.
* '''Model Drift:''' Deterioration in model performance due to changes in data, environment, or context over time.
* '''Intelligent Automation:''' The use of software systems to automate tasks or workflows, which may combine rules-based logic, robotic process automation, and artificial intelligence to execute actions with limited or no human intervention.
* '''Robotic Process Automation (RPA):''' A form of automation that uses software “bots” to execute predefined, rules-based tasks by interacting with applications and systems in the same manner as a human user.
* '''Intelligent Document Processing (IDP):''' An automation technology that applies artificial intelligence, including machine learning and natural language processing, to extract, classify, and validate information from unstructured or semi structured documents. Intelligent automation technologies, including RPA and IDP, are considered AI systems under this policy when they perform decision-making, data transformation, classification, or autonomous actions affecting institutional operations, data, or individuals.

'''5. POLICY'''

'''5.1 AI Governance Model'''

Institutional Leadership shall establish an AI Governance Model to oversee, coordinate, and monitor enterprise use of artificial intelligence across clinical, operational, research, and educational domains.

The AI Governance Model is designed to support consistent, risk-based, and accountable AI adoption while leveraging existing institutional decision-making structures.

'''5.1.1 Governance Functions'''

The AI Governance Model shall ensure the following functions are defined and continuously performed:

* Establish, maintain, and periodically review institutional AI policies, standards, and procedures.
* Provide guidance and recommendations on appropriate AI use across clinical, operational, research, and educational domains.
* Maintain an enterprise inventory of AI systems in use across the institution, including:
** Use-case and workflow classification (e.g., clinical decision support, documentation, monitoring, operations, revenue cycle, research, education).
** AI category or capability type (e.g., predictive, generative, automation, decision support).
** Promote clear ownership and accountability for AI systems, including:
*** IT or system owner
*** Operational or business owner
*** Responsible governance or decision-making body, where applicable.
** Promote a risk-based AI governance approach, with differentiated oversight expectations for lower- and higher-risk AI use cases, as defined in institutional standards or guidance.
** Provide visibility into AI-related risk assessment expectations and outcomes (e.g., privacy, compliance, cybersecurity, ethics, bias, equity).
** Monitor emerging risks, incidents, trends, or concerns related to AI systems and coordinate escalation to appropriate operational, compliance, security, or governance authorities when needed.
** Review aggregate reporting on AI-related incidents, concerns, or suspected policy violations to inform governance priorities and policy updates.
** Support efficient adoption of lower-risk AI use cases through streamlined governance pathways, as defined in institutional standards or guidance.

'''5.1.2 Governance Structure and Participation'''

The AI Governance Model may be supported by one or more coordinating bodies, councils, or working groups as designated by Institutional Leadership. These bodies serve an advisory and coordination role and do not independently approve, authorize, or deploy individual AI systems.

Clinical validation, patient safety determinations, and clinical decision-making authority remain within established clinical governance structures.

Membership and participation may include representatives from:

* Data, Analytics & AI Engineering
* Clinical Informatics
* Clinical Operations
* Information Security
* Privacy
* Enterprise Risk Management
* Compliance and Legal Affairs
* Platform/DevOps Engineering
* Workforce Training and Education
* Research and Academic Governance
* Library and Information Services
* Marketing and Communications

Standing clinician representation shall be incorporated to ensure clinical workflow, safety, and care delivery perspectives are included.

Ad hoc subject-matter experts may participate as needed based on AI use cases, domains, or risk profiles.

'''5.2 Workforce Responsibilities'''

'''5.2.1 Developers/Designers:'''

* Ensure data quality and lawful data use.
* Document model purpose, performance characteristics, limitations, and appropriate use context, including known risks and conditions under which the model should not be relied upon.
* Proactively assesses potential failures and mitigation strategies.
* Evaluate bias and equity impacts prior to deployment.

'''5.2.2 Provisioners:'''

* Ensure accurate and secure data flows into AI systems.
* Ensure systems are integrated only with approved data sources.
* Ensure privacy, security, and governance controls remain intact.

'''5.2.3 Deployers/Users:'''

* Understand the limitations of the AI system.
* Review AI-generated outputs for accuracy, appropriateness, and fairness.
* Do not rely on AI output as the sole basis for clinical or operational decision-making.
* Escalate concerns or unsafe results to the appropriate governance authority.

Clinical validation, determination of clinical accuracy, and assessment of patient safety impact are performed through established clinical governance processes and are not the responsibility of individual developers or end users acting alone.

'''5.3 Branding and Institutional Identity'''

Workforce members may not use AI systems to generate, replicate, modify, or approximate official Nebraska Medicine or University of Nebraska Medical Center (UNMC) logos, emblems, seals, trademarks, or other protected brand assets. All use of official logos and branding elements must continue to follow established Marketing and Brand Governance processes, including formal logo requests and approvals.

'''6. PRINCIPLES AND PRACTICAL REQUIREMENTS'''

The institution’s approach to AI is guided by principles. Each principle includes required practices.

'''6.1 Principle: AI must protect privacy, confidentiality, and security.'''

* 6.1.1 No Protected Health Information (PHI), confidential operational information, proprietary information, or internal restricted data may be entered into any public or unapproved AI application.
* 6.1.2 Access to AI systems that process institutional data must comply with institutional account, device, and security requirements.
** 6.1.2.a Nebraska Medicine: Use of personal email accounts, personal phone numbers, personal cloud accounts, or personal devices to access or process institutional data through AI systems is prohibited unless specifically authorized.
** 6.1.2.b University of Nebraska Medical Center (UNMC): Use of personal devices to access or process institutional data through AI systems is permitted for UNMC workforce members and students when accessed via approved UNMC accounts and in compliance with institutional security, privacy, and data protection requirements.
* 6.1.3 Any AI system used with institutional data must meet institutional security standards and (where applicable) HIPAA requirements.
* 6.1.4 Vendors must not use or share institutional data for purposes beyond what is contractually approved and must be under appropriate legal agreements (e.g., BAA, DUA, MSA/SOW) prior to receiving data access.

'''6.2 Principle: AI must preserve human accountability.'''

A qualified human (“learner intermediary”) must remain responsible for interpreting AI outputs and making final decisions.

* 6.2.1 AI may not act as the final decision-maker in place of clinicians, operational leaders, and other professionals.
* 6.2.2 Workforce members must review AI output before acting on it.
* 6.2.3 Patients have the right to request human review of decisions influenced by AI. Any documentation or records generated in connection with such requests are subject to applicable institutional record-retention and privacy requirements.
* 6.2.4 AI systems must include human oversight appropriate to their level of risk. Oversight mechanisms may be adjusted for use cases based on risk classification, system performance, and validation; however, a qualified human remains accountable for outcomes and decisions influenced by AI.

'''6.3 Principle: AI must be safe, accurate, reliable, fair, and monitored.'''

* 6.3.1 AI systems must be designed, deployed, and used in a manner that prioritizes safety and minimizes the risk of harm to patients, workforce members, and operations, consistent with the institution’s Zero Harm commitment.
* 6.3.2 Developers must evaluate model performance prior to deployment.
* 6.3.3 Red-teaming, scenario testing, or stress testing must be conducted for models used in sensitive contexts.
* 6.3.4 Model performance must be re-evaluated periodically to detect drift, degradation, and bias.
* 6.3.5 Workforce users must escalate concerns or anomalies through appropriate institutional reporting mechanisms, which may include Information Security, Privacy, Clinical Safety, or the AI Oversight Committee, depending on the nature of the issue.
* 6.3.6 AI systems must be monitored over time to ensure they are fit for their intended use. Evaluation criteria and performance expectations must be appropriate to the use case, risk level, and context of use.

'''6.4 Principle: AI use must be transparent.'''

* '''6.4.1 Patient-Facing AI Disclosure''': When AI is used in patient-facing contexts, the involvement of AI must be disclosed.
** '''6.4.1.a Definition of Patient-Facing AI''': For purposes of this policy, patient-facing refers to AI-generated content, recommendations, or interactions that are presented directly to a patient without substantive clinician modification and that may influence a patient’s understanding, decisions, or actions related to their care.
* '''6.4.2 Clinician-Mediated Content''': Use of AI to assist clinicians in drafting, summarizing, or documenting content (e.g., ambient clinical documentation, draft patient instructions, or draft patient portal messages) does not require disclosure when the final content is reviewed, edited, and approved by a clinician and presented as clinician-authored.
* '''6.4.3 Written Disclosure Mechanisms''': Written disclosure of AI usage may be included within institutional Notice of Privacy Practices or similar patient-facing materials, as appropriate.
* '''6.4.4 External Use Attribution''': When AI-generated content is used externally (e.g., presentations, media, publications), attribution to the system used must be clearly noted.
* '''6.4.5 Transparency for Decision-Support Outputs''': When AI systems generate outputs intended to inform clinical, operational, research, or academic decision-making, the system must provide sufficient transparency to allow users to evaluate and validate the output, including access to source references, citations, or supporting context where technically feasible.
* '''6.4.6 Non-Authoritative Presentation of AI Outputs''': For AI systems used in decision-support contexts, outputs must not be presented as authoritative or definitive without appropriate citations, source references, or explanatory context to support human review and judgment.

'''6.5 Principle: AI use must be aligned to mission and values.'''

* 6.5.1 AI must not be used to generate or disseminate unlawful, fraudulent, harmful, plagiarized, inappropriate, or discriminatory content.
* 6.5.2 AI must not be used to create misinformation or content that misrepresents the institution.
* 6.5.3 AI must be designed, deployed, and used in ways that reflect the institution’s values and ethical standards.

'''6.6 Principle: AI must be accessible and inclusive.'''

* 6.6.1 AI systems, tools, interfaces, and AI-generated outputs must comply with applicable accessibility requirements, including the Americans with Disabilities Act (ADA) and institutional digital accessibility standards.
* 6.6.2 AI systems that are patient-facing, learner-facing, workforce-facing, or used in clinical, educational, or operational workflows must be designed and configured to support equitable access for individuals with disabilities.
* 6.6.3 Accessibility considerations must be included as part of AI system intake and risk assessment, and accessibility risks must be mitigated prior to deployment.

'''6.7 Governance of Principles'''

* 6.7.1 Changes to the Principles and Practical Requirements defined in Section 6 require review and approval by the AI Oversight Committee and must follow established institutional policy governance and approval processes.
* 6.7.2 Material changes that alter risk posture, regulatory obligations, or clinical or operational safety requirements may require additional review or approval by executive leadership, Legal Affairs, Compliance, or other governance bodies, as appropriate.
* 6.7.3 AI Embedded in Approved Enterprise Platforms: AI capabilities embedded within approved enterprise platforms (e.g., EHR, analytics, productivity, or operational systems) are subject to institutional AI governance. Initial review and approval may leverage existing platform, clinical, or operational governance processes. Introduction of new AI models or capabilities, material changes to intended use, data sources, autonomy, or risk profile may require additional review and approval under this policy.

'''7. ENFORCEMENT, TRAINING, AND REPORTING'''

'''7.1 Training Requirements'''

* 7.1.1 Workforce members may be required to complete assigned AI education prior to receiving access to AI systems.
* 7.1.2 Ongoing training, refreshers, and/or attestations may be required as systems evolve.

'''7.2 Reporting'''

* 7.2.1 Any suspected misuse, unsafe output, adverse event, or potential violation related to AI systems must be reported promptly through appropriate institutional reporting mechanisms, which may include Information Security reporting channels and/or the Safety Event Reporting System (SOS – RL Solutions), as applicable.
* 7.2.2 Reported AI-related concerns or incidents will be reviewed and triaged to the appropriate oversight area based on the nature of the issue, which may include Information Security, Privacy, Compliance, Ethics, Clinical Safety, Patient Safety, Research Integrity, or other relevant governance bodies.
* 7.2.3 Workforce members must not attempt to conceal AI-related incidents, output anomalies, or errors.

'''7.3 Enforcement'''

* 7.3.1 Violations of this policy may result in disciplinary action consistent with institutional HR policy.
* 7.3.2 Significant violations (e.g., privacy breach, safety risk, intentional misuse) will be escalated to Executive Leadership, Compliance, Legal Affairs, and/or Information Security as appropriate.

'''7.3.3 Response to Escalated AI Concerns'''

* Upon escalation of an AI-related concern, incident, or identified risk, the AI Oversight Committee will review the issue and determine an appropriate course of action based on severity, risk, and impact. Actions may include, but are not limited to:
** Requesting additional evaluation, validation, or monitoring
** Requiring remediation or modification of the AI system or workflow
** Temporarily suspending or restricting use of the AI system
** Referring the issue to appropriate governance bodies (e.g., Information Security, Privacy, Compliance, Patient Safety, or Clinical Governance)
** Recommending continuation, modification, or retirement of the AI system to the appropriate responsible authority
** Final decisions and enforcement actions are executed by the responsible operational, clinical, compliance, or executive governance bodies.

Escalated issues involving patient safety, regulatory compliance, or legal risk will be coordinated with executive leadership and appropriate institutional authorities.

Information Security will periodically review and update this policy as new technologies and risks are identified.

'''STAFF ACCOUNTABILITY'''

Chief Information Security Officer

Vice President, Information Technology

'''Department Approval'''

Signed: Lisa Bazis

Title: Chief Information Security Officer

'''Administrative Approval'''

Signed: Keith Rivera

==== '''Title: Vice President, Information Technology''' ====

This page maintained by [Mailto:mhurlocker@unmc.edu mh].

Artificial Intelligence (AI) Protections Policy

2026-09-09T20:10:38Z

Mhurlocker:

{{DISPLAYTITLE:UNMC AI Use Guidelines}}
{| class="wikitable"
|[[Human Resources]]
|
|[[Safety/Security]]
|
|[[Research Compliance]]
|
|[[Compliance]]
|
|[[Privacy/Information Security]]
|
|[[Business Operations]]
|
|[[Intellectual Property]]
|
|[[Faculty]]
|}
[[Compliance Program]] | [[Compliance Hotline]] | [[Inspections/Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | Electronic Digital Signatures and Records | [[Utilizing Generative AI|UNMC AI Use Guidelines]]| [https://wiki.unmc.edu/index.php?title=Artificial_Intelligence_(AI)_Protections_Policy&action=edit Artificial Intelligence (AI) Protections Policy]

Effective Date: 06/2026

Revised Date: 06/2026

'''<big>Artificial Intelligence (AI) Protections Policy - IM #73</big>'''

'''1. PURPOSE'''

The purpose of this policy is to establish a framework for responsible and transformative use of artificial intelligence (AI) technologies to advance extraordinary patient care, operations, research, and education. AI is a strategic capability that can improve quality, safety, efficiency, and experience. At the same time, we have a duty to govern AI with rigor, transparency, fairness, and equity—protecting patients, workforce members, and enterprise. This policy establishes the protections, expectations, and institutional governance required to enable AI safely and confidently within Nebraska Medicine, UNMC, and the members of the Affiliated Covered Entity (ACE).

'''2. BASIS FOR POLICY'''

Nebraska Medicine/UNMC implements reasonable and appropriate controls for AI systems in alignment with National Institute of Standards and Technology (NIST) standards and guidance. NIST Special Publication 800-53, NIST CSF 2.0, and the HIPAA Privacy and Security Rules outline considerations for these controls.

'''FRAMEWORK REFERENCES'''

NIST SP 800-53 Rev 5: AC-2, AC-3, AU-2, AU-6, CM-2, CM-6, IR-4, IR-5, RA-3, RA-5, SI-3, SI-4, CP-2, CP-4

NIST CSF 2.0: PR.AC-1, PR.AC-4, PR.PT-1, DE.CM-7, PR.IP-1, PR.IP-3, RS.RP-1, RS.CO-1, ID.RA-1, ID.RA-3, PR.IP-2, DE.CM-4, RC.RP-1, RC.IM-1

HIPAA: 45 CFR 164.308, 164.312, 164.524, 164.526, 164.520

'''3. SCOPE'''

The Artificial Intelligence (AI) Protections Policy establishes the governance, protections, obligations, and expectations for the design, development, deployment, and use of AI systems across the enterprise. This policy supports innovation and improvement in care delivery, operations, research, and education while safeguarding privacy, equity, trust, and human oversight. This policy applies to all Artificial Intelligence (current and future) systems that are designed, developed, procured, deployed, operated, or used by Nebraska Medicine, UNMC, or on their behalf, regardless of whether such systems are used by members of the ACE workforce or by affiliated entities performing institutional functions.

For the purposes of this policy, “the institution” or “institutional” refers collectively to Nebraska Medicine, the University of Nebraska Medical Center (UNMC), and the members of the Affiliated Covered Entity (ACE), as applicable. This policy applies to internal AI models, third-party AI models, cloud-based AI models, and publicly available AI systems.

'''4. DEFINITIONS'''

* '''Affiliated Covered Entity (ACE):''' The legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current Nebraska Medical ACE members are Nebraska Medicine, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc. ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members.
* '''Black Box Model:''' An AI system whose internal logic, decision-making processes, or feature contributions are not readily interpretable or explainable to users or stakeholders.
* '''Hallucination (AI Hallucination):''' A phenomenon in which an AI system generates outputs that are factually incorrect, fabricated, or not grounded in source data while appearing plausible or authoritative.
* '''Interpretability:''' The degree to which a human can understand how an AI system produces its outputs, including the ability to trace inputs, logic, and contributing factors.
* '''Extractive AI:''' AI methods that identify, retrieve, or extract existing information from source data without generating new content (e.g., search, classification, summarization using source text).
* '''Retrieval-Augmented Generation (RAG):''' An AI architecture that enhances model outputs by retrieving relevant information from external knowledge sources (e.g., documents, databases) and incorporating that information into the response generation process.
* '''Workforce:''' All faculty, staff, volunteers, trainees, students, independent contractors, and other persons who perform services for, participate in programs of, or act on behalf of the institution, or whose activities are under the direct control of the institution, whether or not they are compensated by the institution.
* '''Developer/Designer:''' Workforce members who create AI systems (including model design, coding, prompt engineering, training, testing, and evaluation).
* '''Provisioner:''' Workforce members permitted by the developer to integrate AI into applications, tools, or workflows (e.g., connecting data sources, managing ingestion pipelines).
* '''Deployer/User:''' Workforce members who implement AI systems into production or use them in day-to-day work to generate content or support decision-making.
* '''Artificial Intelligence (AI):''' A machine-based system that performs tasks requiring human intelligence (e.g., pattern recognition, prediction, reasoning, and recommendation generation).
* '''Artificial Intelligence System (AI System):''' Any data system, software, model, application, or utility that operates in whole or in part using AI. This excludes rules based or deterministic systems that do not perform learning, inference, or probabilistic reasoning.
* '''Bias:''' A systematic tendency or error in judgment, data, or decision-making that can result in unfair, inaccurate, or inequitable outcomes.
* '''AI Bias:''' Bias that arises when an artificial intelligence system produces unfair, misleading, or harmful outcomes due to factors such as training data, algorithm design, system configuration, or human interpretation.
* '''Machine Learning (ML):''' A subset of AI where models learn patterns from data, improving performance over time with limited human intervention.
* '''Deep Learning:''' A subset of ML using multi-layer neural networks capable of processing complex, unstructured data.
* '''Generative AI:''' AI systems that generate original content (text, code, images, audio, etc.) based on learned patterns from training data.
* '''Large Language Model (LLM):''' A type of AI model trained on large-scale text data to interpret and generate natural language.
* '''Foundation Model:''' A large, pre-trained AI model trained on broad and diverse data that can be adapted to perform a wide range of downstream tasks.
* '''Model Drift:''' Deterioration in model performance due to changes in data, environment, or context over time.
* '''Intelligent Automation:''' The use of software systems to automate tasks or workflows, which may combine rules-based logic, robotic process automation, and artificial intelligence to execute actions with limited or no human intervention.
* '''Robotic Process Automation (RPA):''' A form of automation that uses software “bots” to execute predefined, rules-based tasks by interacting with applications and systems in the same manner as a human user.
* '''Intelligent Document Processing (IDP):''' An automation technology that applies artificial intelligence, including machine learning and natural language processing, to extract, classify, and validate information from unstructured or semi structured documents. Intelligent automation technologies, including RPA and IDP, are considered AI systems under this policy when they perform decision-making, data transformation, classification, or autonomous actions affecting institutional operations, data, or individuals.

'''5. POLICY'''

'''5.1 AI Governance Model'''

Institutional Leadership shall establish an AI Governance Model to oversee, coordinate, and monitor enterprise use of artificial intelligence across clinical, operational, research, and educational domains.

The AI Governance Model is designed to support consistent, risk-based, and accountable AI adoption while leveraging existing institutional decision-making structures.

'''5.1.1 Governance Functions'''

The AI Governance Model shall ensure the following functions are defined and continuously performed:

* Establish, maintain, and periodically review institutional AI policies, standards, and procedures.
* Provide guidance and recommendations on appropriate AI use across clinical, operational, research, and educational domains.
* Maintain an enterprise inventory of AI systems in use across the institution, including:
** Use-case and workflow classification (e.g., clinical decision support, documentation, monitoring, operations, revenue cycle, research, education).
** AI category or capability type (e.g., predictive, generative, automation, decision support).
** Promote clear ownership and accountability for AI systems, including:
*** IT or system owner
*** Operational or business owner
*** Responsible governance or decision-making body, where applicable.
** Promote a risk-based AI governance approach, with differentiated oversight expectations for lower- and higher-risk AI use cases, as defined in institutional standards or guidance.
** Provide visibility into AI-related risk assessment expectations and outcomes (e.g., privacy, compliance, cybersecurity, ethics, bias, equity).
** Monitor emerging risks, incidents, trends, or concerns related to AI systems and coordinate escalation to appropriate operational, compliance, security, or governance authorities when needed.
** Review aggregate reporting on AI-related incidents, concerns, or suspected policy violations to inform governance priorities and policy updates.
** Support efficient adoption of lower-risk AI use cases through streamlined governance pathways, as defined in institutional standards or guidance.

'''5.1.2 Governance Structure and Participation'''

The AI Governance Model may be supported by one or more coordinating bodies, councils, or working groups as designated by Institutional Leadership. These bodies serve an advisory and coordination role and do not independently approve, authorize, or deploy individual AI systems.

Clinical validation, patient safety determinations, and clinical decision-making authority remain within established clinical governance structures.

Membership and participation may include representatives from:

* Data, Analytics & AI Engineering
* Clinical Informatics
* Clinical Operations
* Information Security
* Privacy
* Enterprise Risk Management
* Compliance and Legal Affairs
* Platform/DevOps Engineering
* Workforce Training and Education
* Research and Academic Governance
* Library and Information Services
* Marketing and Communications

Standing clinician representation shall be incorporated to ensure clinical workflow, safety, and care delivery perspectives are included.

Ad hoc subject-matter experts may participate as needed based on AI use cases, domains, or risk profiles.

'''5.2 Workforce Responsibilities'''

'''5.2.1 Developers/Designers:'''

* Ensure data quality and lawful data use.
* Document model purpose, performance characteristics, limitations, and appropriate use context, including known risks and conditions under which the model should not be relied upon.
* Proactively assesses potential failures and mitigation strategies.
* Evaluate bias and equity impacts prior to deployment.

'''5.2.2 Provisioners:'''

* Ensure accurate and secure data flows into AI systems.
* Ensure systems are integrated only with approved data sources.
* Ensure privacy, security, and governance controls remain intact.

'''5.2.3 Deployers/Users:'''

* Understand the limitations of the AI system.
* Review AI-generated outputs for accuracy, appropriateness, and fairness.
* Do not rely on AI output as the sole basis for clinical or operational decision-making.
* Escalate concerns or unsafe results to the appropriate governance authority.

Clinical validation, determination of clinical accuracy, and assessment of patient safety impact are performed through established clinical governance processes and are not the responsibility of individual developers or end users acting alone.

'''5.3 Branding and Institutional Identity'''

Workforce members may not use AI systems to generate, replicate, modify, or approximate official Nebraska Medicine or University of Nebraska Medical Center (UNMC) logos, emblems, seals, trademarks, or other protected brand assets. All use of official logos and branding elements must continue to follow established Marketing and Brand Governance processes, including formal logo requests and approvals.

'''6. PRINCIPLES AND PRACTICAL REQUIREMENTS'''

The institution’s approach to AI is guided by principles. Each principle includes required practices.

'''6.1 Principle: AI must protect privacy, confidentiality, and security.'''

* 6.1.1 No Protected Health Information (PHI), confidential operational information, proprietary information, or internal restricted data may be entered into any public or unapproved AI application.
* 6.1.2 Access to AI systems that process institutional data must comply with institutional account, device, and security requirements.
** 6.1.2.a Nebraska Medicine: Use of personal email accounts, personal phone numbers, personal cloud accounts, or personal devices to access or process institutional data through AI systems is prohibited unless specifically authorized.
** 6.1.2.b University of Nebraska Medical Center (UNMC): Use of personal devices to access or process institutional data through AI systems is permitted for UNMC workforce members and students when accessed via approved UNMC accounts and in compliance with institutional security, privacy, and data protection requirements.
* 6.1.3 Any AI system used with institutional data must meet institutional security standards and (where applicable) HIPAA requirements.
* 6.1.4 Vendors must not use or share institutional data for purposes beyond what is contractually approved and must be under appropriate legal agreements (e.g., BAA, DUA, MSA/SOW) prior to receiving data access.

'''6.2 Principle: AI must preserve human accountability.'''

A qualified human (“learner intermediary”) must remain responsible for interpreting AI outputs and making final decisions.

* 6.2.1 AI may not act as the final decision-maker in place of clinicians, operational leaders, and other professionals.
* 6.2.2 Workforce members must review AI output before acting on it.
* 6.2.3 Patients have the right to request human review of decisions influenced by AI. Any documentation or records generated in connection with such requests are subject to applicable institutional record-retention and privacy requirements.
* 6.2.4 AI systems must include human oversight appropriate to their level of risk. Oversight mechanisms may be adjusted for use cases based on risk classification, system performance, and validation; however, a qualified human remains accountable for outcomes and decisions influenced by AI.

'''6.3 Principle: AI must be safe, accurate, reliable, fair, and monitored.'''

* 6.3.1 AI systems must be designed, deployed, and used in a manner that prioritizes safety and minimizes the risk of harm to patients, workforce members, and operations, consistent with the institution’s Zero Harm commitment.
* 6.3.2 Developers must evaluate model performance prior to deployment.
* 6.3.3 Red-teaming, scenario testing, or stress testing must be conducted for models used in sensitive contexts.
* 6.3.4 Model performance must be re-evaluated periodically to detect drift, degradation, and bias.
* 6.3.5 Workforce users must escalate concerns or anomalies through appropriate institutional reporting mechanisms, which may include Information Security, Privacy, Clinical Safety, or the AI Oversight Committee, depending on the nature of the issue.
* 6.3.6 AI systems must be monitored over time to ensure they are fit for their intended use. Evaluation criteria and performance expectations must be appropriate to the use case, risk level, and context of use.

'''6.4 Principle: AI use must be transparent.'''

* '''6.4.1 Patient-Facing AI Disclosure''': When AI is used in patient-facing contexts, the involvement of AI must be disclosed.
** '''6.4.1.a Definition of Patient-Facing AI''': For purposes of this policy, patient-facing refers to AI-generated content, recommendations, or interactions that are presented directly to a patient without substantive clinician modification and that may influence a patient’s understanding, decisions, or actions related to their care.
* '''6.4.2 Clinician-Mediated Content''': Use of AI to assist clinicians in drafting, summarizing, or documenting content (e.g., ambient clinical documentation, draft patient instructions, or draft patient portal messages) does not require disclosure when the final content is reviewed, edited, and approved by a clinician and presented as clinician-authored.
* '''6.4.3 Written Disclosure Mechanisms''': Written disclosure of AI usage may be included within institutional Notice of Privacy Practices or similar patient-facing materials, as appropriate.
* '''6.4.4 External Use Attribution''': When AI-generated content is used externally (e.g., presentations, media, publications), attribution to the system used must be clearly noted.
* '''6.4.5 Transparency for Decision-Support Outputs''': When AI systems generate outputs intended to inform clinical, operational, research, or academic decision-making, the system must provide sufficient transparency to allow users to evaluate and validate the output, including access to source references, citations, or supporting context where technically feasible.
* '''6.4.6 Non-Authoritative Presentation of AI Outputs''': For AI systems used in decision-support contexts, outputs must not be presented as authoritative or definitive without appropriate citations, source references, or explanatory context to support human review and judgment.

'''6.5 Principle: AI use must be aligned to mission and values.'''

* 6.5.1 AI must not be used to generate or disseminate unlawful, fraudulent, harmful, plagiarized, inappropriate, or discriminatory content.
* 6.5.2 AI must not be used to create misinformation or content that misrepresents the institution.
* 6.5.3 AI must be designed, deployed, and used in ways that reflect the institution’s values and ethical standards.

'''6.6 Principle: AI must be accessible and inclusive.'''

* 6.6.1 AI systems, tools, interfaces, and AI-generated outputs must comply with applicable accessibility requirements, including the Americans with Disabilities Act (ADA) and institutional digital accessibility standards.
* 6.6.2 AI systems that are patient-facing, learner-facing, workforce-facing, or used in clinical, educational, or operational workflows must be designed and configured to support equitable access for individuals with disabilities.
* 6.6.3 Accessibility considerations must be included as part of AI system intake and risk assessment, and accessibility risks must be mitigated prior to deployment.

'''6.7 Governance of Principles'''

* 6.7.1 Changes to the Principles and Practical Requirements defined in Section 6 require review and approval by the AI Oversight Committee and must follow established institutional policy governance and approval processes.
* 6.7.2 Material changes that alter risk posture, regulatory obligations, or clinical or operational safety requirements may require additional review or approval by executive leadership, Legal Affairs, Compliance, or other governance bodies, as appropriate.
* 6.7.3 AI Embedded in Approved Enterprise Platforms: AI capabilities embedded within approved enterprise platforms (e.g., EHR, analytics, productivity, or operational systems) are subject to institutional AI governance. Initial review and approval may leverage existing platform, clinical, or operational governance processes. Introduction of new AI models or capabilities, material changes to intended use, data sources, autonomy, or risk profile may require additional review and approval under this policy.

'''7. ENFORCEMENT, TRAINING, AND REPORTING'''

'''7.1 Training Requirements'''

* 7.1.1 Workforce members may be required to complete assigned AI education prior to receiving access to AI systems.
* 7.1.2 Ongoing training, refreshers, and/or attestations may be required as systems evolve.

'''7.2 Reporting'''

* 7.2.1 Any suspected misuse, unsafe output, adverse event, or potential violation related to AI systems must be reported promptly through appropriate institutional reporting mechanisms, which may include Information Security reporting channels and/or the Safety Event Reporting System (SOS – RL Solutions), as applicable.
* 7.2.2 Reported AI-related concerns or incidents will be reviewed and triaged to the appropriate oversight area based on the nature of the issue, which may include Information Security, Privacy, Compliance, Ethics, Clinical Safety, Patient Safety, Research Integrity, or other relevant governance bodies.
* 7.2.3 Workforce members must not attempt to conceal AI-related incidents, output anomalies, or errors.

'''7.3 Enforcement'''

* 7.3.1 Violations of this policy may result in disciplinary action consistent with institutional HR policy.
* 7.3.2 Significant violations (e.g., privacy breach, safety risk, intentional misuse) will be escalated to Executive Leadership, Compliance, Legal Affairs, and/or Information Security as appropriate.

'''7.3.3 Response to Escalated AI Concerns'''

* Upon escalation of an AI-related concern, incident, or identified risk, the AI Oversight Committee will review the issue and determine an appropriate course of action based on severity, risk, and impact. Actions may include, but are not limited to:
** Requesting additional evaluation, validation, or monitoring
** Requiring remediation or modification of the AI system or workflow
** Temporarily suspending or restricting use of the AI system
** Referring the issue to appropriate governance bodies (e.g., Information Security, Privacy, Compliance, Patient Safety, or Clinical Governance)
** Recommending continuation, modification, or retirement of the AI system to the appropriate responsible authority
** Final decisions and enforcement actions are executed by the responsible operational, clinical, compliance, or executive governance bodies.

Escalated issues involving patient safety, regulatory compliance, or legal risk will be coordinated with executive leadership and appropriate institutional authorities.

Information Security will periodically review and update this policy as new technologies and risks are identified.

'''STAFF ACCOUNTABILITY'''

Chief Information Security Officer

Vice President, Information Technology

'''Department Approval'''

Signed: Lisa Bazis

Title: Chief Information Security Officer

'''Administrative Approval'''

Signed: Keith Rivera

==== '''Title: Vice President, Information Technology''' ====

This page maintained by [Mailto:mhurlocker@unmc.edu mh].

UNMC AI Use Guidelines

2026-09-09T20:06:46Z

Mhurlocker: /* Guidelines */

UNMC AI Use Guidelines

2026-09-09T19:57:27Z

Mhurlocker:

UNMC AI Use Guidelines

2026-09-09T19:51:36Z

Mhurlocker:

Artificial Intelligence (AI) Protections Policy

2026-09-09T19:49:02Z

Mhurlocker:

{{DISPLAYTITLE:UNMC AI Use Guidelines}}
{| class="wikitable"
|[[Human Resources]]
|
|[[Safety/Security]]
|
|[[Research Compliance]]
|
|[[Compliance]]
|
|[[Privacy/Information Security]]
|
|[[Business Operations]]
|
|[[Intellectual Property]]
|
|[[Faculty]]
|}
[[Compliance Program]] | [[Compliance Hotline]] | [[Inspections/Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | Electronic Digital Signatures and Records | [[Utilizing Generative AI|UNMC AI Use Guidelines]]| [https://wiki.unmc.edu/index.php?title=Artificial_Intelligence_(AI)_Protections_Policy&action=edit Artificial Intelligence (AI) Protections Policy]

Policy No.:

Effective Date: 06/2026

Revised Date: 06/2026

'''<big>Artificial Intelligence (AI) Protections Policy - IM #73</big>'''

'''1. PURPOSE'''

The purpose of this policy is to establish a framework for responsible and transformative use of artificial intelligence (AI) technologies to advance extraordinary patient care, operations, research, and education. AI is a strategic capability that can improve quality, safety, efficiency, and experience. At the same time, we have a duty to govern AI with rigor, transparency, fairness, and equity—protecting patients, workforce members, and enterprise. This policy establishes the protections, expectations, and institutional governance required to enable AI safely and confidently within Nebraska Medicine, UNMC, and the members of the Affiliated Covered Entity (ACE).

'''2. BASIS FOR POLICY'''

Nebraska Medicine/UNMC implements reasonable and appropriate controls for AI systems in alignment with National Institute of Standards and Technology (NIST) standards and guidance. NIST Special Publication 800-53, NIST CSF 2.0, and the HIPAA Privacy and Security Rules outline considerations for these controls.

'''FRAMEWORK REFERENCES'''

NIST SP 800-53 Rev 5: AC-2, AC-3, AU-2, AU-6, CM-2, CM-6, IR-4, IR-5, RA-3, RA-5, SI-3, SI-4, CP-2, CP-4

NIST CSF 2.0: PR.AC-1, PR.AC-4, PR.PT-1, DE.CM-7, PR.IP-1, PR.IP-3, RS.RP-1, RS.CO-1, ID.RA-1, ID.RA-3, PR.IP-2, DE.CM-4, RC.RP-1, RC.IM-1

HIPAA: 45 CFR 164.308, 164.312, 164.524, 164.526, 164.520

'''3. SCOPE'''

The Artificial Intelligence (AI) Protections Policy establishes the governance, protections, obligations, and expectations for the design, development, deployment, and use of AI systems across the enterprise. This policy supports innovation and improvement in care delivery, operations, research, and education while safeguarding privacy, equity, trust, and human oversight. This policy applies to all Artificial Intelligence (current and future) systems that are designed, developed, procured, deployed, operated, or used by Nebraska Medicine, UNMC, or on their behalf, regardless of whether such systems are used by members of the ACE workforce or by affiliated entities performing institutional functions.

For the purposes of this policy, “the institution” or “institutional” refers collectively to Nebraska Medicine, the University of Nebraska Medical Center (UNMC), and the members of the Affiliated Covered Entity (ACE), as applicable. This policy applies to internal AI models, third-party AI models, cloud-based AI models, and publicly available AI systems.

'''4. DEFINITIONS'''

'''Affiliated Covered Entity (ACE):''' The legally separate covered entities that designate themselves as a single covered entity for the purpose of HIPAA Compliance. Current Nebraska Medical ACE members are Nebraska Medicine, UNMC Physicians, UNMC, University Dental Associates, Bellevue Medical Center and Nebraska Pediatric Practice, Inc.

ACE membership may change from time to time. The Notice of Privacy Practices lists current ACE members.

'''Black Box Model:''' An AI system whose internal logic, decision-making processes, or feature contributions are not readily interpretable or explainable to users or stakeholders.

'''Hallucination (AI Hallucination):''' A phenomenon in which an AI system generates outputs that are factually incorrect, fabricated, or not grounded in source data while appearing plausible or authoritative.

'''Interpretability:''' The degree to which a human can understand how an AI system produces its outputs, including the ability to trace inputs, logic, and contributing factors.

'''Extractive AI:''' AI methods that identify, retrieve, or extract existing information from source data without generating new content (e.g., search, classification, summarization using source text).

'''Retrieval-Augmented Generation (RAG):''' An AI architecture that enhances model outputs by retrieving relevant information from external knowledge sources (e.g., documents, databases) and incorporating that information into the response generation process.

'''Workforce:''' All faculty, staff, volunteers, trainees, students, independent contractors, and other persons who perform services for, participate in programs of, or act on behalf of the institution, or whose activities are under the direct control of the institution, whether or not they are compensated by the institution.

'''Developer/Designer:''' Workforce members who create AI systems (including model design, coding, prompt engineering, training, testing, and evaluation).

'''Provisioner:''' Workforce members permitted by the developer to integrate AI into applications, tools, or workflows (e.g., connecting data sources, managing ingestion pipelines).

'''Deployer/User:''' Workforce members who implement AI systems into production or use them in day-to-day work to generate content or support decision-making.

'''Artificial Intelligence (AI):''' A machine-based system that performs tasks requiring human intelligence (e.g., pattern recognition, prediction, reasoning, and recommendation generation).

'''Artificial Intelligence System (AI System):''' Any data system, software, model, application, or utility that operates in whole or in part using AI. This excludes rules based or deterministic systems that do not perform learning, inference, or probabilistic reasoning.

'''Bias:''' A systematic tendency or error in judgment, data, or decision-making that can result in unfair, inaccurate, or inequitable outcomes.

'''AI Bias:''' Bias that arises when an artificial intelligence system produces unfair, misleading, or harmful outcomes due to factors such as training data, algorithm design, system configuration, or human interpretation.

'''Machine Learning (ML):''' A subset of AI where models learn patterns from data, improving performance over time with limited human intervention.

'''Deep Learning:''' A subset of ML using multi-layer neural networks capable of processing complex, unstructured data.

'''Generative AI:''' AI systems that generate original content (text, code, images, audio, etc.) based on learned patterns from training data.

'''Large Language Model (LLM):''' A type of AI model trained on large-scale text data to interpret and generate natural language.

'''Foundation Model:''' A large, pre-trained AI model trained on broad and diverse data that can be adapted to perform a wide range of downstream tasks.

'''Model Drift:''' Deterioration in model performance due to changes in data, environment, or context over time.

'''Intelligent Automation:''' The use of software systems to automate tasks or workflows, which may combine rules-based logic, robotic process automation, and artificial intelligence to execute actions with limited or no human intervention.

'''Robotic Process Automation (RPA):''' A form of automation that uses software “bots” to execute predefined, rules-based tasks by interacting with applications and systems in the same manner as a human user.

'''Intelligent Document Processing (IDP):''' An automation technology that applies artificial intelligence, including machine learning and natural language processing, to extract, classify, and validate information from unstructured or semi structured documents.

Intelligent automation technologies, including RPA and IDP, are considered AI systems under this policy when they perform decision-making, data transformation, classification, or autonomous actions affecting institutional operations, data, or individuals.

'''5. POLICY'''

'''5.1 AI Governance Model'''

Institutional Leadership shall establish an AI Governance Model to oversee, coordinate, and monitor enterprise use of artificial intelligence across clinical, operational, research, and educational domains.

The AI Governance Model is designed to support consistent, risk-based, and accountable AI adoption while leveraging existing institutional decision-making structures.

'''5.1.1 Governance Functions'''

The AI Governance Model shall ensure the following functions are defined and continuously performed:

* Establish, maintain, and periodically review institutional AI policies, standards, and procedures.
* Provide guidance and recommendations on appropriate AI use across clinical, operational, research, and educational domains.
* Maintain an enterprise inventory of AI systems in use across the institution, including:
** Use-case and workflow classification (e.g., clinical decision support, documentation, monitoring, operations, revenue cycle, research, education).
** AI category or capability type (e.g., predictive, generative, automation, decision support).
** Promote clear ownership and accountability for AI systems, including:
*** IT or system owner
*** Operational or business owner
*** Responsible governance or decision-making body, where applicable.
** Promote a risk-based AI governance approach, with differentiated oversight expectations for lower- and higher-risk AI use cases, as defined in institutional standards or guidance.
** Provide visibility into AI-related risk assessment expectations and outcomes (e.g., privacy, compliance, cybersecurity, ethics, bias, equity).
** Monitor emerging risks, incidents, trends, or concerns related to AI systems and coordinate escalation to appropriate operational, compliance, security, or governance authorities when needed.
** Review aggregate reporting on AI-related incidents, concerns, or suspected policy violations to inform governance priorities and policy updates.
** Support efficient adoption of lower-risk AI use cases through streamlined governance pathways, as defined in institutional standards or guidance.

'''5.1.2 Governance Structure and Participation'''

The AI Governance Model may be supported by one or more coordinating bodies, councils, or working groups as designated by Institutional Leadership. These bodies serve an advisory and coordination role and do not independently approve, authorize, or deploy individual AI systems.

Clinical validation, patient safety determinations, and clinical decision-making authority remain within established clinical governance structures.

Membership and participation may include representatives from:

* Data, Analytics & AI Engineering
* Clinical Informatics
* Clinical Operations
* Information Security
* Privacy
* Enterprise Risk Management
* Compliance and Legal Affairs
* Platform/DevOps Engineering
* Workforce Training and Education
* Research and Academic Governance
* Library and Information Services
* Marketing and Communications

Standing clinician representation shall be incorporated to ensure clinical workflow, safety, and care delivery perspectives are included.

Ad hoc subject-matter experts may participate as needed based on AI use cases, domains, or risk profiles.

'''5.2 Workforce Responsibilities'''

'''5.2.1 Developers/Designers:'''

* Ensure data quality and lawful data use.
* Document model purpose, performance characteristics, limitations, and appropriate use context, including known risks and conditions under which the model should not be relied upon.
* Proactively assesses potential failures and mitigation strategies.
* Evaluate bias and equity impacts prior to deployment.

'''5.2.2 Provisioners:'''

* Ensure accurate and secure data flows into AI systems.
* Ensure systems are integrated only with approved data sources.
* Ensure privacy, security, and governance controls remain intact.

'''5.2.3 Deployers/Users:'''

* Understand the limitations of the AI system.
* Review AI-generated outputs for accuracy, appropriateness, and fairness.
* Do not rely on AI output as the sole basis for clinical or operational decision-making.
* Escalate concerns or unsafe results to the appropriate governance authority.

Clinical validation, determination of clinical accuracy, and assessment of patient safety impact are performed through established clinical governance processes and are not the responsibility of individual developers or end users acting alone.

'''5.3 Branding and Institutional Identity'''

Workforce members may not use AI systems to generate, replicate, modify, or approximate official Nebraska Medicine or University of Nebraska Medical Center (UNMC) logos, emblems, seals, trademarks, or other protected brand assets. All

use of official logos and branding elements must continue to follow established Marketing and Brand Governance processes, including formal logo requests and approvals.

'''6. PRINCIPLES AND PRACTICAL REQUIREMENTS'''

The institution’s approach to AI is guided by principles. Each principle includes required practices.

'''6.1 Principle: AI must protect privacy, confidentiality, and security.'''

* 6.1.1 No Protected Health Information (PHI), confidential operational information, proprietary information, or internal restricted data may be entered into any public or unapproved AI application.
* 6.1.2 Access to AI systems that process institutional data must comply with institutional account, device, and security requirements.
** 6.1.2.a Nebraska Medicine: Use of personal email accounts, personal phone numbers, personal cloud accounts, or personal devices to access or process institutional data through AI systems is prohibited unless specifically authorized.
** 6.1.2.b University of Nebraska Medical Center (UNMC): Use of personal devices to access or process institutional data through AI systems is permitted for UNMC workforce members and students when accessed via approved UNMC accounts and in compliance with institutional security, privacy, and data protection requirements.
* 6.1.3 Any AI system used with institutional data must meet institutional security standards and (where applicable) HIPAA requirements.
* 6.1.4 Vendors must not use or share institutional data for purposes beyond what is contractually approved and must be under appropriate legal agreements (e.g., BAA, DUA, MSA/SOW) prior to receiving data access.

'''6.2 Principle: AI must preserve human accountability.'''

A qualified human (“learner intermediary”) must remain responsible for interpreting AI outputs and making final decisions.

* 6.2.1 AI may not act as the final decision-maker in place of clinicians, operational leaders, and other professionals.
* 6.2.2 Workforce members must review AI output before acting on it.
* 6.2.3 Patients have the right to request human review of decisions influenced by AI. Any documentation or records generated in connection with such requests are subject to applicable institutional record-retention and privacy requirements.
* 6.2.4 AI systems must include human oversight appropriate to their level of risk. Oversight mechanisms may be adjusted for use cases based on risk classification, system performance, and validation; however, a qualified human remains accountable for outcomes and decisions influenced by AI.

'''6.3 Principle: AI must be safe, accurate, reliable, fair, and monitored.'''

* 6.3.1 AI systems must be designed, deployed, and used in a manner that prioritizes safety and minimizes the risk of harm to patients, workforce members, and operations, consistent with the institution’s Zero Harm commitment.
* 6.3.2 Developers must evaluate model performance prior to deployment.
* 6.3.3 Red-teaming, scenario testing, or stress testing must be conducted for models used in sensitive contexts.
* 6.3.4 Model performance must be re-evaluated periodically to detect drift, degradation, and bias.
* 6.3.5 Workforce users must escalate concerns or anomalies through appropriate institutional reporting mechanisms, which may include Information Security, Privacy, Clinical Safety, or the AI Oversight Committee, depending on the nature of the issue.
* 6.3.6 AI systems must be monitored over time to ensure they are fit for their intended use. Evaluation criteria and performance expectations must be appropriate to the use case, risk level, and context of use.

'''6.4 Principle: AI use must be transparent.'''

* '''6.4.1 Patient-Facing AI Disclosure''': When AI is used in patient-facing contexts, the involvement of AI must be disclosed.
** '''6.4.1.a Definition of Patient-Facing AI''': For purposes of this policy, patient-facing refers to AI-generated content, recommendations, or interactions that are presented directly to a patient without substantive clinician modification and that may influence a patient’s understanding, decisions, or actions related to their care.
* '''6.4.2 Clinician-Mediated Content''': Use of AI to assist clinicians in drafting, summarizing, or documenting content (e.g., ambient clinical documentation, draft patient instructions, or draft patient portal messages) does not require disclosure when the final content is reviewed, edited, and approved by a clinician and presented as clinician-authored.
* '''6.4.3 Written Disclosure Mechanisms''': Written disclosure of AI usage may be included within institutional Notice of Privacy Practices or similar patient-facing materials, as appropriate.
* '''6.4.4 External Use Attribution''': When AI-generated content is used externally (e.g., presentations, media, publications), attribution to the system used must be clearly noted.
* '''6.4.5 Transparency for Decision-Support Outputs''': When AI systems generate outputs intended to inform clinical, operational, research, or academic decision-making, the system must provide sufficient transparency to allow users to evaluate and validate the output, including access to source references, citations, or supporting context where technically feasible.
* '''6.4.6 Non-Authoritative Presentation of AI Outputs''': For AI systems used in decision-support contexts, outputs must not be presented as authoritative or definitive without appropriate citations, source references, or explanatory context to support human review and judgment.

'''6.5 Principle: AI use must be aligned to mission and values.'''

* 6.5.1 AI must not be used to generate or disseminate unlawful, fraudulent, harmful, plagiarized, inappropriate, or discriminatory content.
* 6.5.2 AI must not be used to create misinformation or content that misrepresents the institution.
* 6.5.3 AI must be designed, deployed, and used in ways that reflect the institution’s values and ethical standards.

'''6.6 Principle: AI must be accessible and inclusive.'''

* 6.6.1 AI systems, tools, interfaces, and AI-generated outputs must comply with applicable accessibility requirements, including the Americans with Disabilities Act (ADA) and institutional digital accessibility standards.
* 6.6.2 AI systems that are patient-facing, learner-facing, workforce-facing, or used in clinical, educational, or operational workflows must be designed and configured to support equitable access for individuals with disabilities.
* 6.6.3 Accessibility considerations must be included as part of AI system intake and risk assessment, and accessibility risks must be mitigated prior to deployment.

'''6.7 Governance of Principles'''

* 6.7.1 Changes to the Principles and Practical Requirements defined in Section 6 require review and approval by the AI Oversight Committee and must follow established institutional policy governance and approval processes.
* 6.7.2 Material changes that alter risk posture, regulatory obligations, or clinical or operational safety requirements may require additional review or approval by executive leadership, Legal Affairs, Compliance, or other governance bodies, as appropriate.
* 6.7.3 AI Embedded in Approved Enterprise Platforms: AI capabilities embedded within approved enterprise platforms (e.g., EHR, analytics, productivity, or operational systems) are subject to institutional AI governance. Initial review and approval may leverage existing platform, clinical, or operational governance processes. Introduction of new AI models or capabilities, material changes to intended use, data sources, autonomy, or risk profile may require additional review and approval under this policy.

'''7. ENFORCEMENT, TRAINING, AND REPORTING'''

'''7.1 Training Requirements'''

* 7.1.1 Workforce members may be required to complete assigned AI education prior to receiving access to AI systems.
* 7.1.2 Ongoing training, refreshers, and/or attestations may be required as systems evolve.

'''7.2 Reporting'''

* 7.2.1 Any suspected misuse, unsafe output, adverse event, or potential violation related to AI systems must be reported promptly through appropriate institutional reporting mechanisms, which may include Information Security reporting channels and/or the Safety Event Reporting System (SOS – RL Solutions), as applicable.
* 7.2.2 Reported AI-related concerns or incidents will be reviewed and triaged to the appropriate oversight area based on the nature of the issue, which may include Information Security, Privacy, Compliance, Ethics, Clinical Safety, Patient Safety, Research Integrity, or other relevant governance bodies.
* 7.2.3 Workforce members must not attempt to conceal AI-related incidents, output anomalies, or errors.

'''7.3 Enforcement'''

* 7.3.1 Violations of this policy may result in disciplinary action consistent with institutional HR policy.
* 7.3.2 Significant violations (e.g., privacy breach, safety risk, intentional misuse) will be escalated to Executive Leadership, Compliance, Legal Affairs, and/or Information Security as appropriate.

'''7.3.3 Response to Escalated AI Concerns'''

* Upon escalation of an AI-related concern, incident, or identified risk, the AI Oversight Committee will review the issue and determine an appropriate course of action based on severity, risk, and impact. Actions may include, but are not limited to:
** Requesting additional evaluation, validation, or monitoring
** Requiring remediation or modification of the AI system or workflow
** Temporarily suspending or restricting use of the AI system
** Referring the issue to appropriate governance bodies (e.g., Information Security, Privacy, Compliance, Patient Safety, or Clinical Governance)
** Recommending continuation, modification, or retirement of the AI system to the appropriate responsible authority
** Final decisions and enforcement actions are executed by the responsible operational, clinical, compliance, or executive governance bodies.

Escalated issues involving patient safety, regulatory compliance, or legal risk will be coordinated with executive leadership and appropriate institutional authorities.

Information Security will periodically review and update this policy as new technologies and risks are identified.

'''STAFF ACCOUNTABILITY'''

Chief Information Security Officer

Vice President, Information Technology

'''Department Approval'''

Signed: Lisa Bazis

Title: Chief Information Security Officer

'''Administrative Approval'''

Signed: Keith Rivera

==== '''Title: Vice President, Information Technology''' ====

This page maintained by [Mailto:mhurlocker@unmc.edu mh].

UNMC AI Use Guidelines

2026-09-09T19:23:17Z

Mhurlocker:

UNMC AI Use Guidelines

2026-09-09T19:18:20Z

Mhurlocker: Created page with "{{DISPLAYTITLE:UNMC AI Use Guidelines}} {| class="wikitable" |Human Resources | |Safety/Security | |Research Compliance | |Compliance | |Privacy/Information Security | |Business Operations | |Intellectual Property | |Faculty |} Compliance Program | Compliance Hotline | Inspections/Investigations by Third Parties | Research Integrity | Export Control | Code of Conduct | Use of Human Anatomical Material | Clinic..."

Artificial Intelligence (AI) Protections Policy

2026-09-09T19:14:34Z

Mhurlocker: Mhurlocker moved page UNMC AI Use Guidelines to Artificial Intelligence (AI) Protections Policy

Artificial Intelligence (AI) Protections Policy

2026-09-09T19:06:24Z

Mhurlocker:

Policies and Procedures

2026-09-03T19:26:19Z

Mhurlocker:

<table style="background:#F8FCFF; text-align:center" width="90%" cellspacing="0" cellpadding="0" border="0">
<tr>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:100%; line-height:0.95em; border:2px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Human Resources]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Safety/Security]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Research Compliance]] </td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Compliance]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Privacy/Information Security]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Business Operations]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Intellectual Property]]</td>
<td style="border-bottom:2px solid #A3B1BF" width="3"> </td>
<td style="padding:0.5em; background-color:#e5e5e5; font-size:90%; line-height:0.95em; border:1px solid #A3B1BF; border-bottom:solid 2px #A3B1BF"
width="20">[[Faculty]]</td></tr>
</table><br />
==Policy Manual Index==
For assistance with UNMC Policies, please contact [mailto:mhurlocker@unmc.edu Margaret Hurlocker], Policy Coordinator, at 402-559-3207.

{| class="wikitable"
!'''Policy Name'''
!'''Policy No.'''
!'''Effective Date'''
!'''Revised Date'''
!'''Reviewed Date'''
|-
| <big>'''Human Resources Policies'''</big>
|-
|[[Employee Leave]]
|1001
|09/09/05
|03/15/26
|03/15/26
|-
|[[Drug Free Campus]]
|1003
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employment]]
|1004
|11/21/07
|02/16/21
|02/16/21
|-
|[[Work Schedules]]
|1005
|10/17/03
|04/12/19
|04/12/19
|-
|[[Employee Separation]]
|1006
|11/01/07
|10/13/16
|10/10/16
|-
|[[Compensation Administration]]
|1007
|10/31/08
|11/13/15
|11/10/15
|-
|[[Dress|Dress Code]]
|1008
|12/20/05
|03/15/26
|03/15/26
|-
|[[Background Check]]
|1010
|08/01/08
|10/11/21
|10/11/21
|-
|[[Recurring/Additional Payment]]
|1017
|06/25/09
|06/22/23
|06/22/23
|-
|[[Employee Grievance Process]]
|1020
|11/22/06
|03/15/26
|03/15/26
|-
|[[Reduction in Force]]
|1028
|10/25/02
|08/07/17
|07/27/17
|-
|[[Outside Employment]]
|1049
|11/01/06
|07/26/21
|07/09/24
|-
|[[Political Activities]]
|1060
|10/17/03
|03/15/26
|03/15/26
|-
|[[Employee/Dependent Scholarship]]
|1072
|10/25/02
|11/03/15
|12/10/13
|-
|[[Employee Recognition and Reward]]
|1093
|10/25/02
|03/15/26
|03/15/26
|-
|[[Performance Evaluation]]
|1097
|11/22/06
|11/03/15
|05/24/13
|-
|[[Corrective/Disciplinary Action]]
|1098
|03/18/08
|03/15/26
|03/15/26
|-
|[[Non-Discrimination and Harassment]]
|1099
|09/22/09
|03/15/26
|03/15/26
|-
|[[Tobacco-Free Campus]]
|1100
|08/24/09
|11/03/15
|12/10/13
|-
|[[Nepotism]]
|1101
|09/22/09
|03/30/16
|03/30/16
|-
|[[Influenza]]
|1102
|08/25/09
|09/18/17
|09/18/17
|-
|UNMC [[Consensual Relationships]] replaced by [https://www.unmc.edu/titleix/_documents/consensual-relationships-policy.pdf NU Consensual Relationships Policy]
|
|
|
|-
|[[AIDS, HIV, and Other Bloodborne Pathogens]]
|1104
|10/17/03
|11/03/15
|12/10/13
|-
|[[Personnel Action Documentation]]
|1105
|10/04/10
|11/03/15
|12/01/22
|-
|[[Fitness for Duty]]
|1106
|01/05/12
|03/15/26
|03/15/26
|-
|[[Sexual Misconduct]]
|1107
|12/16/14
|08/14/20
|08/14/20
|-
|[[Personnel Files]]
|1108
|03/27/17
|
|12/01/22

|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-03-alternative-worksite-policy.pdf HR-03, Alternative Worksite Policy] for all NU campuses
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/policy-on-chosen-name-and-gender-identity.pdf Policy on Chosen Name and Gender Identity] for all NU campuses, Executive Memorandum No. 40
|
|
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/hr-05-recruitment-and-selection-policy.pdf HR-05, Recruitment and Selection Policy] for all NU campuses
|
|
|
|
|-
|[https://wiki.unmc.edu/index.php/COVID_Vaccination Mandatory COVID-19 Vaccination] deleted effective 07/31/23
|1109
|10/13/21
|
|
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/voluntary-fte-reduction-program.pdf Office/Service and Managerial/Professional Voluntary FTE Reduction Program] for all NU campuses<br />
:[https://www.unmc.edu/human-resources/_documents/nu-values/voluntary-fte-reduction-request-form.pdf Voluntary FTE Reduction Request Form]
|
|10/03/25
|09/01/20
|10/03/25
|-
|<big>'''Safety and Security Policies'''</big>
|-
|[[Safety Policy|Safety]]
|2000
|07/23/99
|04/20/20
|04/20/20
|-
|[[Deadly Weapon]]
|2001
|07/20/90
|12/09/20
|12/09/20
|-
|[[Latex Sensitivity]]
|2003
|05/15/01
|12/05/12
|12/03/12
|-
|[[Bloodborne Pathogens Exposure]]
|2004
|03/17/03
|02/18/14
|07/20/21
|-
|[[Waste Handling]]
|2005
|08/25/06
|01/16/25
|01/16/25
|-
|[[Portable Space Heaters]]
|2006
|08/24/09
|12/02/21
|12/02/21
|-
|[[Children in the Workplace]]
|2007
|10/06/09
|01/04/13
|01/04/13
|-
|[[Pets in the Workplace]]
|2008
|10/06/09
|08/04/15
|08/04/15
|-
|[[Tuberculosis Exposure]]
|2009
|05/11/10
|12/02/21
|12/02/21
|-
|[[Food, Drinks and Cosmetic Use in Laboratory Areas]]
|2010
|11/10/10
|12/02/21
|12/02/21
|-
|[[Medical Surveillance]]
|2011
|02/15/11
|12/02/21
|12/02/21
|-
|[[Enterprise Threat Assessment Response Team]]
|2012
|12/16/11
|09/09/13
|09/09/13
|-
|[[Management of Violent or Aggressive Patients/Visitors]]
|2013
|11/13/12
|N/A
||11/08/12
|-
|[[Youth Safety]]
|2014
|01/03/13
|N/A
|01/03/13
|-
|[[Tours]]
|2015
|12/19/14
|
|
|-
|[https://wiki.unmc.edu/index.php/Small_Appliance Small Appliance and Cooking Devices]
|2016
|12/16/14
|12/02/21
|12/02/21
|-
|[[Unmanned Aircraft]]
|2017
|10/02/17
|
|
|-
|[[Electric Scooter]]
|2018
|05/07/19
|
|
|-
|[[Face Covering]]
|2019
|08/17/20
|10/4/23
|10/04/23
|-
||<big>'''Research Compliance Policies'''</big>
|-
|[[Sponsored Programs]]
|3001
|07/01/98
|08/11/22
|08/11/22
|-
|[[Sponsored Programs Costing]]
|6100
|06/27/02
|11/21/17
|08/11/22
|-
|[[Institutional Base Salary]]
|6102
|02/20/06
|03/09/23
|03/09/23
|-
|[[Sponsored Project Cost Share]]
|6104
|06/27/02
|08/11/22
|08/11/22
|-
|[[Effort Certification]]
|6105
|06/01/06
|08/11/22
|08/11/22
|-
|[[Cost Transfer]]
|6106
|10/27/02
|04/28/23
|04/28/23
|-
|[[Service Center]]
|6107
|06/27/02
|09/17/24
|09/17/24
|-
|[[Subrecipient Policy]]
|6108
|11/24/08
|08/11/22
|08/11/22
|-
|[[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|6110
|02/06/20
|
|08/11/22
|-
||<big>'''Compliance Policies'''</big>
|-
|[[Compliance Program]]
|8000
|11/01/06
|07/09/24
|07/09/24
|-
|[[Compliance Hotline]]
|8001
|08/10/06
|07/10/23
|07/09/24
|-
|[[Inspections/Investigations by Third Parties]]
|6109
|10/16/04
|01/20/23
|07/09/24
|-
|[[Research Integrity]]
|8003
|02/11/05
|10/06/25
|10/06/25
|-
|[[Export Control]]
|8005
|12/18/12
|07/21/23
|07/09/24
|-
|[[Code of Conduct]]
|8006
|03/13/09
|07/09/24
|07/09/24
|-
|[[Use of Human Anatomical Material]]
|8007
|08/10/05
|10/16/24
|10/16/24
|-
|[[Clinical Research and Clinical Trial Professional and Technical Fee Billing]]
|8008
|08/23/18
|07/09/24
|07/09/24
|-
|[[Contracts]]
|8009
|11/01/06
|07/09/24
|07/09/24
|-
|[[Conflict of Interest]]
|8010
|09/04/07
|06/27/23
|07/09/24
|-
|[[Red Flag Identity Theft Prevention Program]]
|8011
|01/13/10
|07/09/24
|07/09/24
|-
|[[Principles of Financial Stewardship]]
|8012
|08/01/10
|07/21/23
|07/09/24
|-
|[[Human Tissue Use and Transfer]]
|8013
|03/15/12
|07/21/23
|07/09/24
|-
|[[Disclosing Foreign Support and International Activities]]
|8014
|06/26/15
|07/09/24
|07/09/24
|-
|[[Health Care Vendor Interactions]]
|8015
|08/31/15
|09/01/20
|07/09/24
|-
|[[Credit Hour Definition]]
|8017
|11/28/16
|08/08/17
|07/23/24
|-
|[[Whistleblower]]
|8018
|04/11/19
|04/11/19
|07/09/24
|-
|[[Electronic Digital Signatures and Records]]
|8019
|08/14/23
|09/13/23
|07/09/24
|-
|[[UNMC AI Use Guidelines]]
|8020
|03/07/25
|08/19/26
|08/19/26
|-
|<big>'''Privacy and Information Security Policies'''</big>
|-
|[[Identification Card]]
|6008
|03/17/03
|11/29/16
|11/12/20
|-
|[[Secure Area Card Access]]
|6009
|03/17/03
|11/29/16
|11/12/20
|-
|[https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Security of Patient and Proprietary Information]
|6045
|11/21/03
|08/01/23
|08/01/23
|-
|[[Computer Use/Electronic Information]]
|6051
|04/25/07
|04/24/25
|04/24/25
|-
|[[Retention and Destruction/Disposal of Private and Confidential Information]]
|6056
|03/17/03
|draft 10/28/22
|
|-
|[[Use and Disclosure of Protected Health Information]]
|6057
|03/17/03
|03/28/24
|04/22/24
|-
|[[Notice of Privacy Practices]]
|6058
|03/17/03
|10/28/22
|04/22/24
|-
|[[Access to Designated Record Set]]
|6059
|03/17/03
|06/06/24
|06/06/24
|-
|[[Accounting of PHI Disclosures]]
|6061
|03/17/03
|06/06/24
|06/06/24
|-
|[[Patient/Consumer Complaints]]
|6062
|03/17/03
|04/22/24
|04/22/24
|-
|[[Vendors|Vendors]]
|6063
|03/17/03
|
|
|-
|[[Fax Transmissions]]
|6065
|03/17/03
|09/22/22
|09/22/22
|-
|[[Psychotherapy Notes]]
|6066
|03/17/03
|09/22/22
|07/24/24
|-
|[[Facility Security]]
|6067
|03/17/03
|07/14/17
|11/12/20
|-
|[[Conditions of Treatment Form]]
|6070
|03/17/03
|
|
|-
|[[Informed Consent for UNMC Media]]
|6030
|02/01/94
|10/17/03
|10/17/03
|-
|[[Transporting Protected Health Information]]
|6073
|01/30/12
|
|
|-
|[[Honest Broker]]
|6074
|08/26/15
|
|
|-
|[[Social Security Number | Use of Social Security Number]]
|6085
|09/22/15
|03/30/18
|03/30/18
|-
|[[Third Party Registry | Third Party Registry Selection]]
|6300
|06/27/16
|draft 09/22/22
|
|-
|[[Information Security Awareness and Training]]
|6301
|07/14/16
|06/06/24
|06/06/24
|-
|[[Patient Privacy Investigations and Levels of Violation]]
|6302
|11/02/20
|04/22/24
|04/22/24
|-
|[[Use and Disclosure of PHI for Training Health Care Professionals]]
|6303
|08/19/22
|06/06/24
|06/06/24
|-
|[[Disclosures of PHI as Permitted or Required by Law]]
|6304
|10/28/22
|07/24/24
|07/24/24
|-
|[[Disclosure of PHI for Law Enforcement Purposes]]
|6305
|10/28/22
|10/28/22
|07/24/24
|-
|<big>'''Business Operations Policies'''</big>
|-
|[[General Accounting]]
|3000
|10/25/02
|09/19/19
|09/19/19
|-
|[[SBIR/STTR Program Participation]]
|3002
|11/15/06
|
|
|-
|[[Supplemental Compensation Plan]]
|3039
|10/25/02
|
|
|-
|[[Facilities Management/Planning]]
|4000
|07/01/98
|10/25/23
|
|-
|[[Purchasing]]
|5000
|04/01/01
|09/24/20
|09/24/20
|-
|[[Strategic Communications]]
|6001
|10/17/03
|01/03/22
|01/03/22
|-
|[[Facility Identification]]
|6004
|10/15/99
|
|
|-
|[[Serving Alcoholic Beverages]]
|6012
|09/10/99
|
|
|-
|[[Travel and Reimbursement]] - replaced by [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/university-of-nebraska-travel-policy.pdf NU Travel Policy]
|
|
|
|
|-
|[https://www.unmc.edu/coronavirus/campus-guidance.html#travel UNMC Campus Guidance on Travel]
|
|
|
|
|-
|[[State Vehicles]] - replaced by [https://fleetmanagement.unl.edu/policies NU Fleet Management Policies]|
|
|
|
|-
|[[Reproducing Copyrighted Materials]]
|6036
|07/01/98
|
|
|-
|[[Bank Card Processing]]
|6050
|01/10/07
|DRAFT 07/20/21
|
|-
|[[Student Training Agreement]]
|6052
|07/01/98
|
|
|-
|[[Volunteer]]
|6053
|09/10/99
|10/19/21
|10/19/21
|-
|[[Cash Handling]]
|6054
|10/17/03
|12/29/12
|12/29/12
|-
|[[Fraud]]
|6055
|08/21/00
|08/17/15
|07/29/15
|-
|[[Assigning Research Lab Space]]
|6071
|01/06/06
|09/22/22
|09/22/22
|-
|[[Space Scheduling and Fundraising]]
|6072
|11/19/07
|08/24/19
|08/24/19
|-
|[[Academic Personnel Records]]
|6075
|11/07/07
|
|
|-
|[[Cell Phone|Cellular Device]]
|6076
|09/10/08
|05/16/24
|05/16/24
|-
|[[Off-campus Graphic Design and Related Printing]]
|6077
|04/01/10
|05/16/24
|05/16/24
|-
|[https://wiki.unmc.edu/index.php/Off-campus_Photography Off-campus Photography, Videography]
|6078
|04/01/10
|01/03/22
|01/03/22
|-
|[[Tax Exempt Financing and Tracking of Both Qualified Use and Non-Qualified Use of Research Space]]
|6079
|05/11/10
|09/20/13
|09/20/13
|-
|[[Secondary Logos]]
|6080
| 01/06/11
|01/03/22
|01/03/22
|-
|[[Social Media]]
|6081
|12/07/11
|01/03/22
|01/03/22
|-
|[[Sensitive Equipment Tracking]]
|6082
|02/25/13
|N/A
|02/25/13
|-
|[[International Visitors]]
|6083
|05/01/13
|06/01/21
|06/01/21
|-
|[[Accounts Receivable Management]]
|6084
|09/26/13
| 03/02/23
|03/02/23
|-
|[[Internal Audit]] - replaced by [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services/charter Internal Audit Charter] and the [https://www.unmc.edu/internal-audit/index.html UNMC Internal Audit and Advisory Services webpage].
|
|
|
|
|-
|[[Regulations on the Use of University Facilities and Grounds]]
|6086
|12/13/18
|08/05/25
|08/05/25
|-
|[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/policies/bf-01-moving-relocation-policy.pdf University of Nebraska Moving Relocation Policy]
|
|
|
|
|-
|[[Tuition Remissions]]
|6088
|10/19/21
|
|
|-
|[[Collections Management]]
|6089
|11/09/21
|
|
|-
|[[Web Governance]]
|6090
|11/16/21
|
|
|-
|[[Student Fee Administration]]
|6091
|03/13/25
|03/13/25
|03/13/25
|-
|[[Establishing Campus Policies]]
|6092
|3/07/25
|3/07/25
|3/07/25
|-
|<big>'''Intellectual Property Policies'''</big>
|-
|[[Science/Technology Committee]]
|7000
|03/16/05
|03/15/10
|04/12/21
|-
|[[Division of Net Royalty and Proceeds]]
|7001
|03/16/05
|05/03/21
|05/03/21
|-
|<big>'''Faculty Policies'''</big>
|-
|[[Faculty Transfer]]
|9000
|02/06/20
|
|
|}

{|
|
'''For UNMC faculty, student and staff use only.<br />'''
|}

Updated by [mailto:mhurlocker@unmc.edu mh]

Artificial Intelligence (AI) Protections Policy

2026-09-03T19:23:59Z

Mhurlocker: /* Guidelines */

Artificial Intelligence (AI) Protections Policy

2026-09-03T19:19:14Z

Mhurlocker:

Artificial Intelligence (AI) Protections Policy

2026-08-20T16:39:21Z

Mhurlocker: /* Guidelines */

On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects

2026-08-13T19:36:14Z

Mhurlocker: /* Additional Information */

Subrecipient Policy

2026-08-13T19:28:36Z

Mhurlocker: /* Additional Information */

Service Center

2026-08-13T19:10:59Z

Mhurlocker: /* Responsibilities */

Cost Transfer

2026-08-13T19:06:42Z

Mhurlocker: /* Additional Information */

Effort Certification

2026-08-13T18:56:10Z

Mhurlocker: /* Additional Information */