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.

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• 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

ACA0001: Conflict of Interest Policy for Faculty Members, Trainees, Faculty Supervisors, Institutional Decision Makers, and Investigators of the University of Texas MD Anderson Cancer Center

ACA0006: Recruitment of Tenure Track Faculty Policy

ACA0009: Acceptance of Tobacco-Related Funds Policy

ACA0016: Effort Certification Policy

ACA1028: Preceptorship 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

ACA0048: Faculty Leave 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

ACA0066: Moonlighting Policy

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

ADM0113: Annual Budget Policy

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

ADM0121: Gift Policy

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

ADM0134: Memberships Policy

Business and Finance Administration - Office of Sponsored Programs

ADM0983: Advance Setup of Sponsored Project Account Base Center

Business and Finance Administration - Sales Tax

ADM0144: Sales Tax Policy

Business and Finance Administration - Supply Chain Management

ADM0125: Historically Underutilized Business (HUB) and Federal Small Business Concerns (SBC) Forums Policy

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

ADM1265: Small Business Concerns (SBC) Use of Manufacturing North American Industry Classification System (NAICS) Codes 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

ADM0932: Sponsorship for Clinical Educational Activities Without Continuing Medical Education (CME)
Credit Policy

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

ADM1112: Social Media Policy

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

ADM1273: Institutional Conflict of Interest Policy for the University of Texas MD Anderson Cancer Center and Institutional Decision Makers

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

ADM0391: Patient Privacy: Right to Access Protected Health Information in the Designated Record
Set Policy

ADM0392: Patient Privacy: Right to Receive Accounting of Disclosures Policy

ADM0393: Patient Privacy: Right to Request Privacy Protections and Other Restrictions on the
Disclosure of Protected Health Information Policy

ADM0395: Patient Privacy:  Joint Notice of Privacy Practices Policy

ADM0396: Patient Privacy:  Authorization for the Use and Disclosure of Protected Health Information Policy

ADM0401: Patient Privacy:  Uses and Disclosures of Protected Health Information Policy

ADM1032: Patient Privacy:  Disclosures of a Patient's Protected Health Information to Individuals Involved in the Patient's Care 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

ADM0160: Gifts-in-Kind Policy

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

ADM0230: Parking Policy

ADM0231: Control Policy for MD Anderson-Owned Vehicles

ADM0232: Postage Policy

ADM0233: Art Program Policy

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

ADM0238: Space Survey Policy

ADM1122: Document Delivery Policy for Facilities Central Library

Facilities - Patient Care & Prevention Facilities

ADM0975: Facility Asset Request (FAR) Policy

Human Resources -  Compensation

ADM0245: Overtime Policy

ADM0247: Shift Differential Policy

ADM0248: Longevity Pay Policy

ADM0249: Call Pay 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

ADM0258: Tobacco Free 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

ADM0266: Grievance Policy

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

ADM0277: Modified Duty Policy

ADM0278: Drug-Free Campus & Workplace Policy

ADM0348: HIV/HBV 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

ADM0289: Attendance Policy

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

ADM0323: Realignment Policy

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

ADM1039: Ombuds Office Policy

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