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Procedures for the Development, Approval and Review of Policy Instruments

Classification number 1100.01
Parent policy Policy Framework
Framework category Legal, Compliance and Governance
Approving authority Governance, Nominations and Human Resources Committee
Policy owner University Secretary
Approval date May 31, 2018
Review date June 2021
Last updated Editorial Amendments, February 18, 2020
Supersedes Procedures for the Development, Approval and Review of Policy Instruments, November 2014


These Procedures are intended to ensure clarity and consistency in the administration of policy instruments across the University.


For the purposes of these procedures the following definitions apply:

Approval Authority” means a body or position that has authority to approve, amend, review and revoke a Policy Instrument.

Deliberative Body” means a University body or committee responsible for discussion and consideration and provides recommendations for Policy Instruments prior to submission for approval.  

Editorial Amendment” means an amendment that is essentially editorial in nature or does not change the purpose, scope or substantive content of the Policy Instrument. An editorial amendment may clarify language, correct typos, update contact information or titles to reflect current organizational structure, or modify the formatting of a Policy Instrument.

Policy Advisory Committee (PAC)” means an advisory committee and deliberative body, established to conduct Policy Assessments and deliberate on Policy Instruments as set out in Appendix A of the Policy Framework.

“Policy Assessment” means a review of a draft Policy Instrument as described in the PAC Terms of Reference (Appendix C of the Policy Framework).

Policy Category” means one of the defining categories of Policy Instruments as set out in the Policy Framework, as amended.

Policy Framework” means the Policy Framework, as amended, which is the enacting Policy for these procedures.

Policy Instrument” means the different tools and documents that are used to provide direction in the governance and administration of the University.  Policy instruments may have application within a single organizational unit (Local) or across more than one organizational unit (University-wide).

Policy Lead” means the individual(s) responsible for drafting, reviewing, or amending a Policy Instrument and for facilitating consultation throughout the development and approval process.

Policy Owner” means the position responsible for overseeing the implementation, administration and interpretation of a Policy Instrument. 

Policy Sponsor” means the Vice-President or delegate who oversees the organizational unit proposing a new Policy Instrument.

“Substantive Amendment” means an amendment other than an Editorial Amendment. It changes the purpose, scope or substantive content of the Policy Instrument. An amendment may be minor in scope but still substantive in nature if it affects stakeholder groups (including students), reassigns organizational authority, or changes existing processes or responsibilities.

Scope and authority

These Procedures apply to the development, approval and review of all University Policy Instruments.

The University Secretary is responsible for strategic oversight and overall administration of the Policy Framework and its associated Procedures and for ensuring the Framework meets University compliance obligations and is aligned with the strategic goals of the University.  

The University Secretary will assign a delegate who is responsible for supporting the administration of the Policy Framework and its associated Procedures.  This position is responsible for:

  • Coordinating the development, approval, amendment, publication and review of Policy Instruments in accordance with the Policy Framework and these Procedures;
  • Providing advice on amendments to existing Policy Instruments to the Policy Owners for incorporation in subsequent updates;  
  • Providing advice and guidance to policy developers and other staff across the University on Policy Instrument development, consultation, communication, implementation and review processes;
  • Developing resources that support Policy Instrument development, evaluation and review;
  • Ensuring that final drafts of new or amended Policy Instruments are compliant with the Policy Framework;
  • Publishing and maintaining approved Policy Instruments in the Policy Library;
  • Managing and coordinating a Policy Instrument review schedule. 
  • Preparing an annual report on the development, amendment, revocation and review of University Policy Instruments.

The Policy Owner is responsible for overseeing the administration of Policy Instruments under his/her jurisdiction in accordance with the Policy Framework and these Procedures.  For any given Policy Instrument, the Policy Owner may assign a Policy Lead to carry out the following responsibilities :

  • Developing, preparing amendments to and consulting on Policy Instruments;
  • Facilitating and evaluating the communication and implementation of Policy Instruments;
  • Monitoring adoption and compliance with Policy Instruments that have been implemented;
  • Conducting a review of existing Policy Instruments according to established procedures.


Identifying Policy Needs

  1. A policy need will arise from identifying:
    • Gaps where no Policy Instrument currently exists and where development of an instrument is the appropriate mechanism for addressing the issue;
    • Amendments that are required to existing Policy Instruments for compliance or administrative reasons.
    • Where an existing Policy Instrument should be revoked.
  2. The development of new Policy Instruments requires the approval of a Policy Sponsor.
  3. The amendment or proposed revocation of an existing Policy Instrument requires the approval of the Policy Owner.
  4. The Policy Sponsor or Policy Owner will consult with the University Secretary delegate prior to beginning the development, amendment or revocation of a Policy Instrument.
  5. The University Secretary delegate will advise on the need for a Policy Instrument, the appropriate type of instrument, as well as provide guidance on the processes under the Policy Framework.
  6. The Policy Sponsor or Policy Owner will assign an individual who will act as the Policy Lead.

Preliminary Stakeholder Consultation

  1. The Policy Lead will identify key policy stakeholders paying particular attention to faculty, staff and students, and will conduct preliminary consultations with those key policy stakeholders.  When applicable, the Policy Lead will give particular consideration to the policies of any and all strategic institutional partners with whom the University shares academic or administrative operations that may overlap or otherwise affect the proposed policy (e.g. Durham College).
  2. Preliminary consultation should include the gathering of feedback on:
    • Content of the Policy Instrument;
    • Operational practicality;
    • Potential impact and resources required for implementation and compliance;
    • Planning and requirements for successful communication and implementation.
  3. Information on preliminary consultations will be provided when instruments are submitted for deliberation and approval.
  4. The Policy Advisory Committee is available as a resource to Policy Leads in the early stages of a policy project to aid in identifying stakeholders, consider consultation and implementation planning, and provide recommendations on whether a policy need can be achieved by modifying or clarifying existing Policy Instruments.


  1. The Policy Lead is responsible for the drafting of all Policy Instruments.
  2. All Policy Instruments will be accompanied by a completed Policy Instrument Review and Planning Form.
  3. Policy Instruments will be prepared using the official University templates (Appendix D).
  4. Sections of the templates may not be added or removed.  Where a section is not required, the wording “This section intentionally left blank” will be used.
  5. The Policy Lead will ensure Policy Instruments are coherent and are consistent with existing legislation and Policy Instruments.
  6. Where a Policy is being drafted or amended, any Procedures, Directives, Guidelines or other associated documents (e.g. templates, schedules) will also be drafted or amended at the same time in order to ensure consistency and compliance with the Policy.

Consultation on Drafts

  1. The Policy Lead will facilitate broader consultation on draft Policy Instruments with key policy stakeholders.
  2. Consultation will be done in all cases except where amendments to an existing Policy Instrument are essentially editorial in nature.
  3. The Policy Lead will incorporate feedback, as appropriate, and advise the policy stakeholders of action taken related to the feedback provided.
  4. When Policy Instruments are submitted for deliberation and approval they will specify: 
    • The key stakeholders who were consulted with;
    • The mechanism used to gather feedback and opinions;
    • A description of how stakeholders’ views were incorporated into the draft of the instrument;
    • If consultation was not done an explanation of why it was not necessary.

Mandatory Consultation and Assessment

  1. Before submitting a Policy Instrument for deliberation, mandatory consultation steps and a Policy Assessment must be completed, as set out in Appendix A of the Policy Framework.
  2. Draft Policy Instruments will be shared with the University community on the University Secretariat’s website to solicit feedback.
  3. Policy Instruments submitted to a committee or governing body for mandatory consultation or Policy Assessment will be accompanied by a document satisfying the requirements of section 10.4. Submissions will be made to the University Secretary delegate, who will ensure compliance with the Policy Framework before it is shared.
  4. The required format of consultation is set out in Appendix A of the Policy Framework.


  1. In order to ensure compliance with the Policy Framework, the Policy Lead will submit copies of all draft documents to the University Secretary delegate before submission to any Deliberative Body or Approval Authority.
  2. Drafts and amendments of Policy Instruments will be submitted to a respective Deliberative Body for review prior to being submitted to the Approval Authority.
  3. The Deliberative Body is based on the Policy Category of the Policy Instrument, as set out in Appendix A of the Policy Framework.
  4. The Deliberative Body will provide feedback and recommendations on a draft. The Deliberative Body may recommend:
    1. Approval of the Policy Instrument;
    2. Approval of the Policy Instrument with recommended changes; or
    3. Further consultation and/or changes, followed by further deliberation.


  1. Once feedback and recommendations on draft Policy Instruments are provided by the Deliberative Body, the instruments will be forwarded to the appropriate Approval Authority along with the recommendations of the Deliberative Body.
  2. Approval Authorities are set out in Appendix A of the Policy Framework. 
  3. Appendices to Policy Instruments form part of the instrument and are subject to the same approval, amendment, consultation and review processes as the instrument they are a part of.

Approved Policy Instruments

  1. When approved, Policy Instruments will receive a final review by the University Secretariat prior to communication and implementation.
  2. Within two weeks of the approval of a Policy Instrument by the Approval Authority the University Secretary delegate will:
    • Notify the Policy Sponsor and Policy Owner of when the approved Policy Instrument is ready for publication;
    • Provide a final draft of the Policy Instrument to the Policy Sponsor and Policy Owner including classification number, approval date and mandatory review date;
    • Publish copies of the Policy Instrument to the Policy Library.
    • Report on approved Policy Instruments to other Deliberative Bodies and Approval Authorities.


  1. Once notified by the University Secretary delegate that a Policy Instrument is ready for publication, the Policy Owner is responsible for ensuring information is communicated to policy stakeholders according to the communication and implementation plan.
  2. The Policy Owner will evaluate the implementation of the Policy Instrument and report on the implementation to the Approval Authority within one year of implementation.


  1. Policy Instruments will be reviewed at least once every three years.  Such reviews will include a review of the Policy Instrument text as well as an assessment of compliance with the practices governed by the text.
  2. Where a Policy has specific legislative requirements for reporting it will be reviewed against the stated compliance needs.
  3. Where a Policy has Procedures, Guidelines and Directives associated with it, they will be reviewed at the same time as the parent Policy.
  4. The University Secretariat will provide tools and templates to facilitate documentation for Policy Instrument review.
  5. Amendments to Policy Instruments may be done at any time prior to the stated review date. 
    1. Where a Policy Instrument is amended prior to the stated review date, the review will still take place according to the original stated date.
    2. Informal reviews of existing Policy Instruments may be done at any time but will not replace a formal scheduled review.
    3. Where significant concerns related to the content, consistency or compliance with a Policy Instrument exist, a formal review may be undertaken prior to the stated date.
    4. Where it is determined that a Local Policy Instrument conflicts with a University Policy Instrument, the Local Policy Instrument will be reviewed and amended to align with University Policy.
  6. Reviews  of Policy Instruments will take into consideration:
    • The extent to which Policy objectives are being achieved;
    • An assessment of the adoption and use of the Policy Instrument;
    • Whether the Policy Instrument complies and remains consistent with University strategic goals as well as existing legislation and Policy Instruments;  
    • Any deleterious impacts resulting from the Policy Instrument; and
    • Whether updates to format or classification are required.
  7. Review of Policy Instruments will result in recommendations for one or more of the following outcomes:
    • No amendment;
    • Editorial amendment;
    • Substantive Amendment;
    • Revocation;
    • Development of new or additional supporting Policy Instruments;
    • Additional communication and education of policy stakeholders.
  8. Upon completion of the review the review outcomes will be reported to the designated Approval Authority.
  9. Further development or amendment of Policy Instruments as a result of review outcomes will be done in accordance with the Policy Framework and these Procedures.


  1. Policy Instruments requiring amendments will be submitted to the University Secretary delegate with a Policy Instrument Review and Planning Form for review and a determination if the amendment is an Editorial Amendment or Substantive Amendment.
  2. Amendments are subject to the deliberation and approval path set out in Appendix A of the Policy Framework.

Monitoring and review

These Procedures will be reviewed every three years.  The Policy Advisory Committee is responsible for reviewing and evaluating these Procedures.


Relevant legislation

University of Ontario Institute of Technology Act, 2002, S.O. 2002, c 8, Sch. O

By-Law Number 1 of the University of Ontario Institute of Technology, as amended

By-Law Number 2 of the University of Ontario Institute of Technology (effective September 1, 2018)



Related policies, procedures & documents

Policy Framework

Policy Instrument Review and Planning Form

Policy Instrument Drafting Guidelines (In development)

Policy Instrument Templates

Policy Development and Review Cycle

Policy Instrument Review Guidelines (In development)





Policy (word)

Procedures (word)

Guidelines/Directives (word)



Local Administrative Approval Authorities


Organizational Unit:




Approved by:


Approval date:




Deliberative Body

Approval Authority

Local ACD Policy



Local ACD Procedure



Local ACD Directive



Local ACD Guideline




Local Administrative approval authorities are subject to approval by the Vice-President responsible for the organizational area. Positions eligible to be assigned as approval authorities are set out in the Delegation of Authority Chart, Appendix B to the Policy Framework.