Handbook of Operating Procedures
The institutional policies and procedures of The University of Texas MD Anderson Cancer Center (MD Anderson) are contained in the Handbook of Operating Procedures (HOP). An institutional policy is developed for significant organizational issues that generally affect more than one department, operational area, or discipline, or is mandated to be an institutional policy by an accreditation or state/federal agency.
Questions related to MD Anderson’s institutional policies and procedures should be directed to Maggie Newell, Executive Director, Institutional Compliance Programs, by email at mnewell@mdanderson.org or InstitutionalPolicies@MDAnderson.org, or by telephone at 713-745-6636.
View our online database of institutional policies, or navigate our Handbook of Operating Procedures sections below.
- Windows users: Recommended browsers are Edge or Chrome; Internet Explorer 11 and Firefox also are supported.
- Mac users: Recommended browser is Chrome; Safari is not supported.
- Finding a specific institutional policy:
- Once the database opens, press <ctrl> F to activate the "Find" function and search for a particular term.
- You also may click the column headers to sort the database by that category.
Please note:
- In general, the institutional policies listed in our online database may not include policies related to institutional safety and security, computer network access, or information security.
- Many of our policies reference MD Anderson's Data Classification Guidelines; please refer to these for additional information on data security and management.
ACADEMIC POLICIES
Administration Policies
ACA0006: Recruitment of Tenure Track Faculty Policy
ACA0009: Acceptance of Tobacco-Related Funds Policy
ACA0016: Effort Certification Policy
Faculty Appointments, Promotions, and Tenure
ACA0020: Faculty Appointments, Promotions and Tenure Committee Policy
ACA0021: Faculty Recruitment Policy
ACA0022: Faculty Leadership Search Committee Policy
ACA0023: Faculty Appointments Policy
ACA0024: Faculty Term Tenure Policy
ACA0025: Faculty Tenure Track (Probationary Position) Policy
ACA0026: Dual and Joint Faculty Appointment Policy
ACA0027: Multi-Year Appointment Award Policy
ACA0028: Appointment of Visiting Professors and Visiting Scientists Policy
ACA0029: Faculty Administrative Appointments Policy
ACA0030: Faculty Promotion Policy
ACA0031: Voluntary Separation Policy for Faculty and Medical Physicists
ACA0032: Post-Retirement Faculty Appointment Policy
ACA0058: Non-Renewal of Faculty Appointment Policy
ACA0059: Termination of Employment of a Faculty Member Policy
Faculty Policies and Procedures
ACA0033: Endowed Positions Award and Renewal Policy
ACA0034: Ashbel Smith Professorship Policy
ACA0036: Faculty Scholars Program Policy
ACA0039: Conflict Management Policy
ACA0041: Faculty Appeal Policy
ACA0042: Faculty Coaching and Development Policy
ACA0043: Faculty Standards of Conduct Policy
ACA0044: Faculty Compensation Program Policy
ACA0045: Faculty Loan Repayment Program Policy
ACA0052: Annual Faculty Performance Appraisal Policy
ACA0054: Division Head and Department Chair Upward Evaluation Policy
ACA0056: Philanthropic Funds for Research and Education Policy
ACA0060: Establishing or Changing Names of Divisions and Departments Policy
ACA1117: Faculty Financial Exigency Policy
School of Health Sciences
ACA0061: School of Health Sciences Appointment and Promotion Policy
School of Health Professions
ACA1106: School of Health Professions Catalog
ACA1222: Student Rights Under the Family Educational Rights and Privacy Act (FERPA)
ACA1264: School of Health Professions Conduct and Discipline Policy
Trainee and Alumni Affairs - Academic Program Administration and Oversight
ACA0083: Graduate Medical Education (GME) Committee Policy
ACA1199: Education Agreement Policy
Trainee and Alumni Affairs - Academic Programs EO
ACA0079: Equal Opportunity Policy for AVA/TAA Trainees
ACA0081: Accommodating Disabilities Policy for AVA Trainees
Trainee and Alumni Affairs - Academic Recruitment and Appointment
ACA0087: Relocation Expenses Policy for AVA Trainees
ACA0088: Graduate Medical Education (GME) Recruitment and Selection Policy
ACA0089: GME Appointment/Reappointment Policy
ACA1212: Observational Experience Policy
Trainee and Alumni Affairs - Benefits
ACA0063: On-Call Meal Ticket Program Policy for AVA/TAA Trainees
Trainee and Alumni Affairs - Compensation and Moonlighting
Trainee and Alumni Affairs - Conduct
ACA0068: Education & Training Disciplinary Actions and Appeals Policy
ACA1194: Academic Actions and Appeals in Training Programs Policy
Trainee and Alumni Affairs - Dispute Resolution
ACA0078: Conflict Resolution Policy for AVA-Trainees
Trainee and Alumni Affairs - Evaluation and Advancement
ACA0084: GME Advancement Policy
ACA0085: GME Assessment and Evaluation Policy
ACA0086: Duty Hours and Working Environment Policy for AVA-Trainees
ACA0922: Certification of Training Policy for AVA Trainees
Trainee and Alumni Affairs - Leaves and Absences
ACA0096: Attendance Policy for AVA/TAA Trainees
ACA0097: Vacation Leave Policy for AVA/TAA Trainees
Trainee and Alumni Affairs - Termination of Appointment
ACA0062: Non-Renewal and Termination of Appointment Policy for AVA/TAA Trainees
ADMINISTRATION POLICIES
Business and Finance Administration - Accounts Payable
ADM0106: Accounts Payable Policy
Business and Finance Administration - Administrative Records Management
ADM0107: Records Management Policy
Business and Finance Administration - Alcoholic Beverages
ADM0108: Alcoholic Beverages Policy
Business and Finance Administration - Asset Management
ADM0109: Asset Control Policy Manual
ADM0110: Asset Management Capital Asset Policy
ADM0112: Facilities Project Funding and Capitalization Policy
ADM0907: Bar-Code Standards Policy
Business and Finance Administration - Budget & Forecasting
Business and Finance Administration - Business Entertainment
ADM0114: Business Entertainment Policy
Business and Finance Administration - Controller's Office
ADM1210: Management and Expenditure of Endowment Funds Policy
Business and Finance Administration - Employee Reimbursement
ADM0116: Employee Reimbursement Policy
Business and Finance Administration - Financial Reporting
ADM0118: Access to Financial Systems and Financial Reporting Policy
Business and Finance Administration - General Accounting
ADM0120: Non-Patient Billing Policy
Business and Finance Administration - Gifts
Business and Finance Administration - Grants and Contracts Accounting
ADM0122: Grants and Contracts Policy
ADM0999: Grants and Contracts Billing Policy
ADM1110: Financial Closeout of Sponsored Projects Policy
ADM1111: Residual Funds from Sponsored Projects Policy
ADM1228: Cost Transfers Policy for Sponsored Programs
Business and Finance Administration - Internal Control
ADM0123: Internal Control Policy
ADM1100: Policy on Department Fund Transaction Reviews
Business and Finance Administration - Inventory Management
ADM0124: Operational and Consumable Inventory Policy
Business and Finance Administration - Memberships
Business and Finance Administration - Office of Sponsored Programs
ADM0983: Advance Setup of Sponsored Project Account Base Center
Business and Finance Administration - Sales Tax
Business and Finance Administration - Supply Chain Management
ADM0126: Historically Underutilized Business (HUB) Subcontracting Policy
ADM0127: Materials Management Services Policy
ADM0128: Supply Chain Management Policy
ADM0130: Value Analysis Team (Formerly Known as Materials Use Evaluation MUE) Policy
ADM0131: Good Faith Effort Policy
ADM0132: HUB & Federal Small Business Mentoring Policy
ADM0133: Small Business Concerns (SBC) Utilization Policy
ADM1128: Vendor Access and Conduct Policy
ADM1170: Small Business Concerns (SBC) Subcontracting Policy
Business and Finance Administration - Travel Management
ADM0145: Travel Management Policy
CME & Conference Management - Contract
ADM0147: CME / Conference Management Service Contract Policy
CME & Conference Management - Non-CME Conferences
ADM1020: Funding for Non-CME Conferences and/or Meetings Policy
CME & Conference Management - Sponsorship & CME
ADM0148: Sponsorship and Continuing Medical Education (CME) Credit for Educational Activities Policy
Communications
ADM0414: News Media Assistance Policy
ADM0415: Filming on Campus Policy
ADM1050: Policy Regarding Use of Institutional Images
Compliance Program
ADM0156: Institutional Compliance Program Policy
ADM0157: Fraud, Waste, and Abuse Policy
ADM0262: Political Activity Policy
ADM1254: Policy on Concealed Handgun Carriage on MD Anderson’s Campus
Compliance Program - Policy and Procedure Development and Review
ADM0158: Institutional Policy and Procedure Development and Implementation Policy
Compliance Program - Privacy and Confidentiality
ADM0159: Protecting the Confidentiality of Social Security Numbers Policy
ADM0264: Confidentiality Policy
ADM0342: Business Associate Agreement Policy
ADM0343: Limited Data Set and Data Use Agreement Policy
ADM0389: Disposal of Confidential or Sensitive Information Policy
ADM0390: Patient Privacy: Right to Request Amendment of PHI Policy
ADM0392: Patient Privacy: Right to Receive Accounting of Disclosures Policy
ADM0395: Patient Privacy: Joint Notice of Privacy Practices Policy
ADM0401: Patient Privacy: Uses and Disclosures of Protected Health Information Policy
ADM1033: Patient Privacy: Breach Notification Policy
ADM1176: Patient Privacy: Safeguarding Paper PHI Policy
ADM1180: Patient Privacy: De-identification of Protected Health Information (PHI) Policy
ADM1197: Patient Privacy: Patient Identification on Whiteboards Policy
Development - Gifts
ADM0161: Conditional Gifts Policy
Development - Procedures
ADM0162: Patient Privacy: Fundraising Policy
Environmental Health & Safety - Chemical Safety
ADM0172: Mercury-Free Environment Policy
Environmental Health & Safety - Emergency Preparedness
ADM1097: Emergency Notification Policy
Environmental Health & Safety - General Safety
ADM1282: Emergency Management Program Policy
Environmental Health & Safety - Occupational Safety
ADM0227: Reporting, Investigating and Preventing Accidents Policy
ADM0981: Occupational Noise Assessment Policy
Facilities - Campus Operations
ADM0231: Control Policy for MD Anderson-Owned Vehicles
ADM0234: Public and Retail Space Use Policy
ADM1145: Shuttle and Valet Operations Policy
ADM1182: Displays and Signage for Areas Open to the Patients and Public Policy
Facilities - Facilities Administration
ADM1122: Document Delivery Policy for Facilities Central Library
Facilities - Patient Care & Prevention Facilities
ADM0975: Facility Asset Request (FAR) Policy
Human Resources - Compensation
ADM0246: Compensatory Time Policy
ADM0247: Shift Differential Policy
ADM0250: Employee Workweek and Classification Policy
ADM0252: License, Certification and Registration Renewal Reimbursement Policy
ADM0253: Employee Awards Policy
Human Resources - Conduct
ADM0254: Non-Retaliation Policy
ADM0255: Conflict of Interest and Conflict of Commitment Policy
ADM0256: Corrective Action Policy
ADM0257: Violence Prevention Policy
ADM0260: Accommodating Closely Held Personal and/or Religious Beliefs Policy
ADM0261: Appearance and Demeanor Policy
ADM0265: Intra-Facility Transportation Policy
ADM3384: Sexual Misconduct Under Title IX: Reporting, Process, and Resources Policy
Human Resources - Dispute Resolution
ADM0268: Classified Employees Appeal Policy
Human Resources - Employee and Organization Development
ADM0269: New Employee Orientation Policy
ADM0270: Tuition Assistance Policy Related to Institutional Job Needs
ADM0273: Staff Development and Training Policy
ADM1168: Institutional Mandatory Training Policy
Human Resources - Employee Health
ADM0274: Fitness for Duty Policy
ADM0275: Employee Assistance Program Policy
ADM0276: Workers' Compensation Insurance Policy
ADM0278: Drug-Free Campus & Workplace Policy
ADM1068: Management of Occupational Exposure to Blood or Body Fluids Policy
ADM3215: Lactation in the Workplace Policy
Human Resources - Employee Records and Information
ADM0143: Time and Leave Data Collection Policy
ADM0280: Official Personnel Files (OPF) Policy
ADM0282: Identification (ID) Badge Policy
ADM0283: Employee, Faculty, Trainee, and Applicant Educational Credentialing Policy
Human Resources - Equal Employment Opportunity
ADM0284: Equal Employment Opportunity Policy
ADM0285: Sexual Misconduct Prevention Policy
ADM0286: Accommodating Disabilities in the Workplace Policy
ADM0287: Affirmative Action Policy
Human Resources - Executive Recruitment
ADM1013: Administrative Staff Recruitment and Selection Policy
Human Resources - Leave and Absences
ADM0297: Employee Reporting Requirements During Emergency Conditions Policy
ADM0302: Time Off and Leave Policy
Human Resources - Performance Management
ADM0304: Performance Evaluation Policy
ADM0305: Position Description Policy
Human Resources - Recruitment
ADM0307: Recruitment and Selection Policy
ADM0308: Probationary Period of Employment Policy
ADM0309: Drug Detection and Deterrence Policy
ADM0311: Preferred Supplier Temporary Agency Personnel Policy
ADM0312: Criminal and Personal Background Check Policy
ADM0315: Relocation Loan Policy
ADM0317: Employment of Minors Policy
ADM0318: Appointment of Relatives Policy
ADM0321: Employee Referral Incentive Plan Policy
ADM1161: Internal Job Application Policy
ADM1162: Position Posting Policy
Human Resources - Termination from Employment
Human Resources - Worklife
ADM0279: Employee Discounts and Services Program ("iDeal") Policy
ADM0320: Alternative Work Arrangements Policy
ADM1085: In-State Workers Telecommuting Policy
Information Technology - Information Technology Management
ADM1187, Electronic Confidential and Restricted Confidential Information Access and Storage Policy
Internal Audit - General Information
ADM0336: Internal Audit Policy
Legal - Legal Services
ADM0337: Ethics for State Employees Policy
ADM0340: Use of State-Owned Property, Equipment, Services, Funds, and Resources Policy
ADM3352: Expressive Activities in MD Anderson's Common Outdoor Areas Policy
Legal - Protection of Ownership
ADM0345: Intellectual Property Policy
Marketing
ADM0351: AdverRetising Placement Policy
Ombuds Office
Operations - Administrative
ADM0911: Business Planning and Approval Policy
ADM1023: Patient Visitation Policy
Operations - Patient Services
ADM0360: Luggage Concierge Policy
ADM0402: Patient/Family Notary Services Policy
ADM1147: Patient and Family Member Pager Policy
ADM3577: Youth Protection Policy
Telehealth Services - Institutional Videoconferences
ADM0423: Institutional Video Conference/Web Conference Policy
UT Police at Houston
ADM1104: Clery Act Policy on Reporting Criminal Activity
RESEARCH POLICIES
RES3524: Allocation of Resources for Faculty Conducting Research Policy
RES3525: Bridge Funding and Salary Support Policy
RES3526: Subrecipient Monitoring Policy
RES3528: Research Start-Up Funds Policy
RES3531: Indirect Cost Rates Policy
RES3532: Scientific Publication Policy
RES3533: Research Review Policy
RES3534: Research Misconduct Policy
RES3535: Principles for Scientific Research Policy
RES3537: Institutional Research Contribution from Philanthropic Gifts Policy
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