Creating, Reviewing and Administering University Policy


Category General
Approval Senior Leadership Team (SLT)
Responsibility Provost and Vice-Principal (Academic)
Date initially approved April 2013
Date of last revision August 2021

Purpose/Reason for Policy:

To define a coordinated and consistent process for the development, approval and administration of all University Policies, and Procedures.

Scope of this Policy:

Subject to the limitations set out below, this policy applies to all University staff and faculty who are responsible for developing, approving and administering University Policies and their associated Procedures and Guidelines.

This policy does not apply to regulations that are or will be communicated in the Academic Calendar(s) (academic regulations, degree requirements, and regulations about admissions, fees, and financial aid) and nor does it apply to University Policies, Procedures, Guidelines or regulations which originate within the Senate, the Board, Faculty Boards and Executive Councils of Schools or their respective committees .

Management decisions must not be inconsistent with approved University Policies or Procedures.

Policy Statement:

  • While University Policies may encompass elements of procedure, most University Policies should focus on providing guidance on the operation of the University based on the articulation of key principles and values.  University Policies should strive to answer the question "what" and not "how".
  • University Policies change infrequently, and such changes are subject to approval by the Approval Authority for a University Policy.
  • Most University Procedures or Guidelines will be linked to an explicit University Policy, but it is not mandatory and University Procedures may be approved without an express policy supporting them, if advisable in the view of the Approval Authority.

 Approval Processes
For a policy to become a University Policy, it must be approved by the relevant Authority. Procedures and Guidelines are generally developed and approved by the Senior Administrative Officer responsible for the University Policy.

All University Policies, Procedures and Guidelines must be presented in the relevant approved template - attached to this Policy's Procedure titled Procedure for Creating, Reviewing and Revising University Policy.

Review Cycle
All University Policies, Procedures and Guidelines are to be reviewed on a regular and scheduled cycle, to be recommended by the Policy Advisory Subcommittee (PASC).Substantive changes to existing University Policies, Procedures and Guidelines are subject to the same requirements as new University Policies, Procedures and Guidelines.

Subject to legislative requirements or collective agreements, a University Policy or Procedure remains in force unless formally revoked by the Approval Authority. The previous version of a University Policy or Procedure is automatically revoked when a new version is approved by the relevant Approval Authority, whether the Approval Authority remains the same or has changed.


Policy Advisory Subcommittee

Prior to submission to the Approval Authority for final approval, all University Policies and Procedures must be submitted to the University Policy Advisory Subcommittee. The Subcommittee will review such Policies and Procedures:

  • To ensure all Policies are coherent in nature and scope
  • To ensure Policies have been checked for compliance with relevant external legislation and internal Policies and Procedures, including Board of Trustees By-laws, special resolutions, and existing collective agreements
  • To ensure terminology and format are consistent and readable
  • To ensure appropriate consultation has been undertaken
  • To provide a central library to avoid duplication or overlap of Policies and Procedures
  • To review communications plan
  • To identify potential risks, costs, and infrastructure requirements
  • To review the Equity Impact Assessment

The Terms of Reference for the Policy Advisory Subcommittee are attached to this Policy as Appendix 'A'.

University Secretariat

There will be one central library incorporating all approved University Policies, Procedures and Guidelines, managed by the University Secretariat.


The Principal, the Provost and Vice-Principals are responsible for ensuring that, within their areas of responsibility, appropriate plans to ensure compliance with University Policies are developed, resourced, kept current, and implemented.

The Deputy Provost, Associate Vice-Principals, Vice-Provosts, Deans, Executive Directors, Directors and University Librarian are responsible for:

  • Ensuring adherence to University Policy is integrated into all planning and decision-making within their portfolios;
  • Ensuring programs are developed, resourced, implemented, evaluated, and maintained to implement University Policies effectively.
  • Ensuring that Policies or Procedures of application within one administrative unit, or across multiple administrative units which are wholly contained within the portfolio of a single Senior Administrative Officer, are consistent with broader University Policies of general application.

Department Heads, Managers and Principal Investigators are responsible for:

  • Ensuring University Policies are implemented in their Program, Department or research project as applicable;
  • University Policies are integrated into all aspects of planning and decision-making within the Program or Department.

Every employee (faculty or staff) is responsible for complying with University Policies in the course of performing their duties.


Approval Authority:  The Approval Authority for a University Policy is the Senior Leadership Team (SLT) or, with respect to matters within their respective jurisdictions under the Queen's Charter, the Board of Trustees and /or the Senate. Policies of more local application may be approved by the Principal, a Vice-Principal, AVP, Dean, Associate Dean or Administrative Directors depending on the context.  The Approval Authority for a Procedure need not be the same as the Approval Authority of the Policy which supports the Procedure. The University Policy Advisory Committee will provide advice regarding the appropriate Approval Authority in particular instances.

Contact Officer: A contact officer is the person who should be contacted for any matters relating to a University Policy, Procedure or Guideline.

Guidelines: Guidelines provide instructions that facilitate completion of a Procedure or application of a University Policy in differing circumstances.  Guidelines provide assistance when the use of judgment is required for the application of a University Policy.  Often they will establish a "best practice" for applying a University Policy and can assist in interpreting the Policy.

Policy:  A policy guides the operation of the University and is informed by the University's key principles and values. Generally, policies are enduring in nature and are approved at the most senior levels of the University.  Some policies can stand alone, but most often will be accompanied by associated procedures and/or guidelines.

Procedure:  A procedure details the interrelated and sequential steps and/or actions that must be taken to implement a University Policy.  They are mandatory and may be subject to routine changes based on operating practice.  Although procedures may be approved by the Approval Authority for a University Policy, they are generally approved by the Senior Administrative Officer responsible for that Policy.

Senior Administrative Officer:  The senior administrative officer is responsible for ensuring the communication of a University policy, development of associated Procedures, interpretation and awareness of the Policy, and for monitoring compliance. A senior administrative officer would normally be at the level of the Principal, the Provost, a Vice-Principal, Deputy Provost, AVP, Vice-Provost, Dean, University Librarian, Executive Director or Director.

University Policy:  A Policy which has application across more than one Faculty, School, or Academic Department or across multiple administrative units not wholly contained within the portfolio of a single  Senior administrative Officer and/ or applies to the University, as a whole.

Contact Officer Executive Director, Office of the Provost and Vice-Principal (Academic)
Date for Next Review 2018 April
Related Policies, Procedures and Guidelines N/A
Policies Superseded by this Policy There was no University-wide policy/procedure approval process in place prior to this policy. This policy replaces any local department / faculty / office processes.






The Policy Advisory Subcommittee (PASC) is a subcommittee created by, and advisory to, SLT. PASC has an advisory and coordinating role regarding the development of administrative policies and procedures, but not a decision-making role. It does not have the authority to approve a policy, nor to allocate resources.     

Subject to this paragraph, all policies and procedures which have application across more than one Faculty, School or across multiple administrative units and/ or applies to the University, as a whole must be reviewed by PASC prior to submission for approval by the appropriate approval body.  Policies or procedures which originate with the standing or ad hoc committees of either the Board of Trustees, the University Senate, Faculty Boards, or Executive Councils of Schools are not required to be reviewed by PASC before approval.  Such bodies are, however, able to request PASC review if deemed useful in the view of that committee or its respective senior approval body.

To ensure consistency and coordination in the development, approval and administration of all University Policies.


One representative from each of:

Financial Services

Human Resources

Labour Relations

Marketing and Communications

Human Rights and Equity Office

Office of Indigenous Initiatives

University Counsel

VP Research or delegate

Provost or delegate

Principal or delegate

Vice-Provost and Dean of Student Affairs or delegate


AMS Vice President (University Affairs)

SGPS Vice President, Professional

1 faculty member selected by the Provost after consultation with the Deans

1 SLT Member - Committee Chair

1 Internal Audit to be advisory to the committee

A Secretary assigned by the Chair will provide executive support.

To receive proposals for University Policy from SLT or from other members of the University community and to make recommendations to SLT on whether a new University policy is needed (or whether the purpose can be achieved by modifying or clarifying an existing policy, or through guidelines or procedures).  University Policy is defined as policy which has application across more than one Faculty, School or multiple administrative units and/ or applies to the University, as a whole.   Policies or procedures which have application only within one operational area do not fall within the purview of PASC. To advise proponents of policy and interested members of the community on policy approval process and requirements. Where a new policy is being recommended for development, to provide a template, advice about consultation (including advice about the need for legal review), and identify the appropriate approval path.  In particular, implications of any policy for students, both undergraduate and graduate, should be carefully considered and the consultation process for each policy designed with this in mind.   The Provost or his/her delegate will be primarily responsible for raising possible implications for students arising from any policy proposal and the Committee, as a whole, will be mindful of the possible impacts of any proposed policy on students. To assist SLT, as required, in an evaluation of the implications of proposed policies, including potential risks, costs, and infrastructure requirements. To assess polices under development and review in light of legislation, collective agreements and, in particular, the University's obligations under the Accessibility for Ontarians with Disabilities Act (AODA).

Once a draft policy is received, to review the process of consultation and the implementation and communication plan, and to make a recommendation to SLT for initial approval, either by SLT itself, or in the case of policies or procedures proposed by the administration, by the Board or the Senate as the subject matter relates to their respective jurisdictions. To undertake periodic reviews of existing policies, identifying anachronisms, gaps and overlaps, and monitoring the effectiveness of the institution's ongoing administration of its policies.

PASC will, as its first task, propose a policy to establish the overall policy approval process for the University, together with templates for policy writing, for the approval of SLT. PASC shall be responsible for ensuring the establishment of a definitive repository of University Policy and will propose a process for overseeing a systematic review of University Policies.

All policies shall have an identified position which is responsible for the policy and which will conduct regular reviews of the policy.