I. Scope

This is a Whole University Policy.

II. Purpose & Policy Statement

William & Mary is committed to supporting and promoting a culture of integrity and accountability in which all university employees and students act in an ethical, honest, and lawful manner. William & Mary communicates expectations for such conduct to members of the university community through written policies and procedures. University members are required to follow and uphold all applicable policies and procedures and to comply with this policy when creating and maintaining policies and procedures.
 
Responsibility for developing, implementing, and training to a specific policy falls to the designated Responsible Office. The Office of Compliance & Equity (OC&E) is responsible for ensuring that a Responsible Office follows proper policy development and approval processes in compliance with this policy.  The Responsible Office is accountable for the policy’s accuracy, timeliness, and education and awareness to appropriate audiences.

 

III. Definitions

Administrative Policy
An Administrative Policy addresses operational expectations applicable to the whole university and/or compliance with applicable laws, regulations, policies and procedures. 

Board of Visitors (BOV) Policy
A BOV Policy is an Administrative Policy that addresses matters of university governance or requires BOV approval to be effective. The authority to determine when a Policy warrants Board of Visitors’ level of approval rests with the ELT in consultation with the President and University Counsel.

Enforcement
Consequences for failure of an individual, department, unit, division or school to comply with the requirements of a policy or consequences for engaging in prohibited conduct of a Policy.  Consequences may include, but are not limited to, corrective actions, educational requirements, financial implications and/or disciplinary action.

Executive Leadership Team
Senior leadership of the university administration; the designated group that works with the President to set strategic direction and communicate it to stakeholders.

Guidelines
Guidelines provide additional detail and direction on Administrative or BOV Policy and suggest a recommended or preferred course of action or behavior; guidelines are generally relevant to implementing university policy and do not supplant the requirements of established Policy. Guidelines are distinct from policies and procedures which mandate actions by university members. Guidelines should not be used in lieu of a policy when certain behaviors and actions are required of university members.

Interim Policy
An Interim Policy is a provisional Administrative or BOV Policy that fulfills an emergent need, which requires implementation pending the prescribed approval process. An Interim Policy is limited in term to one year or less.

Local Policy
Local Policy meets the unique needs of, and generally applies to or affects, one unit, division, department, or school.

Minor Revisions
Minor revisions are those changes that do not alter the scope or application of an existing Policy. Examples of Minor Revisions include, but are not limited to, title changes for individuals or departments, spelling corrections, updated hyperlinks, or addition of new relevant documents.

Policy
A Policy articulates requirements and expectations for behavior, actions, and activities of the university community. A Policy may require or prohibit an action, support compliance with applicable laws and regulations and/or mitigate risk.

Policy Library
The Policy Library is the official repository of all interim and final Administrative or BOV Policies currently in effect. Local Policies reside in the applicable unit, division, department, or school.

Policy Program
OC&E’s Policy Program oversees the development, review and approval processes for policies and procedures. This Program provides guidance to the Responsible Office, President, ELT, or respective designees and maintains a current and comprehensive Policy Library website to provide access to all Whole University Policies.

Policy Statement
The Policy Statement describes the purpose, key requirements, and expectations of the Policy.

Procedures
Procedures include mandatory actions and processes necessary to comply with a Policy, support compliance with applicable laws and regulations, and mitigate risk. Policies may or may not include procedures. For purposes of this Policy, all references to Policies include procedures unless otherwise noted.

Related Documents
Related Documents are documents critical to the development of relevant Policies and Procedures and may include federal regulations, state regulations, state policies and other William & Mary Policies, Procedures and Guidelines.

Responsible Office
The Responsible Office is the administrative office responsible, through the action of an individual policy owner within the office, for developing and implementing the Policy, including ensuring accuracy of the subject matter, training appropriate audiences, enforcing and monitoring compliance with the policy, and timely review.

Subject Matter Expert
Subject Matter Experts are individuals who have significant knowledge and skills in a particular area or topic through extended study and practice.

Substantive Revisions
Substantive Revisions are those that alter the scope or application of an existing Policy and therefore require approval through the prescribed Policy process.

Timely Review
For purposes of this policy, timely review means a required review and revision at least as often as every three (3) years (triennial review) and more frequent revisions as required by legal, regulatory, and other developments.

University Policy Work Group
A standing university committee with representation from major central administrative areas that is charged with identifying gaps and setting priorities for new policy creating or revisions to existing policies, ensuring periodic review of all university policies, evaluating draft policies for clarity, implementation issues, and contradiction or duplication with existing polices, and ensuring transparent communication to the university community regarding new policy adoption and substantive revisions to existing policies.

Whole University Policy
This refers to Administrative Policies and BOV Policies that apply to William & Mary as a whole university.  Pursuant to Va. Code Sec. 23.1-2807 the university provides for the administration of the Virginia Institute of Marine Science (VIMS) and VIMS has been expressly incorporated into the university’s Management Agreement which grants the university restructured financial and operational authority. Accordingly, all policies that apply to the whole university include VIMS and the Batten School of Coastal & Marine Sciences at VIMS.

IV. Policy

A. Administrative Policy

Creation of or substantive revisions to an Administrative Policy applicable to William & Mary as a whole university require:

1. Approval of the development of a new Administrative Policy by the President’s Executive Leadership Team (ELT) member with oversight of the Responsible Office that is proposing the creation or revision of an Administrative Policy.
2. A review by the University Counsel.
3. A period of 10 business days to allow for comment from the University Policy Working Group. 
4.  Final review from the ELT and approval by the ELT member with oversight of the Responsible Office prior to becoming effective.
5. Certain Administrative Policies require additional approval from the Board of Visitors (BOV).

B. Local Policies

Policies applying to individual units or departments within the university do not require review from the President’s ELT or approval from the BOV. Local Policies must not conflict with Administrative or BOV Policies. If a Local Policy conflict exists, the conflicting elements of the Local Policy have no effect.

C. Interim Policy

In certain circumstances, an Administrative Policy requiring expedited implementation may take effect with interim approval according to this policy (See §V.D).

D. Policy Library

OC&E maintains in the Policy Library official versions of all Whole University Policies in effect and is responsible for retention and destruction of policy documents in accordance with the Library of Virginia’s Records Retention and Disposition Schedule.

V. Procedures

A. Creating New Administrative & BOV Policies

1. Initiation Phase: Responsible Office assesses the need for an Administrative Policy through consultation with the ELT member with oversight of the Responsible Office and/or the University Policy Work Group. Assessment shall include:
   • A summary of the Policy purpose
   • The goal of the Policy (e.g., requirement or prohibition of conduct, risk mitigation, compliance with state or federal regulation, state policies, protection of health or safety, fiscal responsibility)
   • The justification for creating an Administrative Policy
2. Concept Awareness: The ELT member with oversight of the Responsible Office will communicate the concept of the Administrative Policy to the entire ELT.
3. Drafting Phase: The Responsible Office is responsible for completing the following steps prior to seeking final approval:
   • Designate an individual representative within the Responsible Office who will communicate with the OC&E and draft the policy in consultation with stakeholders and relevant subject matter experts.
   • Consider appropriate substantive requirements, potential impact on university stakeholders, and other university Policies either in final or draft form.
   • Contact the Office of University Counsel, as needed, for legal advice regarding the need, scope, and substantive requirements of the new Policy.
4. Review Phase:
   • The Responsible Office submits a draft policy utilizing the William & Mary Policy Template and an Executive Summary of Proposed Policy to OC&E.
     • The Executive Summary of Proposed Policy includes: the reason for the Policy’s creation; general points covered in the Policy; information noting the stakeholder offices or personnel that have provided input to the Policy draft; other universities’ policies or resources considered in drafting; and a general assessment of the Policy’s impact.
   • OC&E reviews the draft Policy to ensure proper formatting, compliance with applicable regulations, compatibility with other Administrative and BOV Policies, and consistency and clarity throughout the policy.
   • OC&E shares the draft Policy with the University Policy Work Group and initiates the 10-business day review.
   • OC&E submits the draft Policy and Executive Summary to the Office of University Counsel for legal review and further revisions or recommendations to the draft according to relevant legal advice.
5. Final Approval Phase:
   • The ELT member with oversight of the Responsible Office submits the Policy draft and Executive Summary to the entire ELT for review, questions, suggestions, and comments.
   • The Responsible Office, in cooperation with OC&E, responds to questions, comments, and presents a further revised draft for final approval to the ELT member with oversight of the Responsible Office.
   • The ELT member with oversight of the Responsible Office approves the Administrative policy or returns the draft policy to the Review Phase for more editing and collaboration with stakeholders.
   • Final approval shall be made by the ELT member with oversight of the Responsible Office.
6. Implementation Phase: After obtaining final approval and before the effective date of the Administrative Policy, the Responsible Office shall:
   • Submit the final approved Policy to OC&E for inclusion in the Policy Library.
   • Notify the whole university community via W&M Digest and/or Student Happenings of the new policy’s effective date.
   • Communicate, educate, and train appropriate audiences on policy content and compliance.

B. Maintaining Existing Administrative & BOV Policies 

1. Compliance Monitoring and Enforcement: The Responsible Office is charged with monitoring for compliance with Policy requirements; identifying and reporting or addressing compliance issues; and evaluating the Policy’s effectiveness at achieving desired results and any necessity for changes on an ongoing basis.
2. Timely Review: The Responsible Office must review a Policy at least as often as every three years and follow the procedures below, as appropriate. OC&E will provide advance notice that the triennial review date is forthcoming.
   • No revisions necessary: The Responsible Office notifies OC&E that the triennial review is complete and no revisions are necessary. The next revision date will be set for three years from the date of completion.
   • Minor revisions: The Responsible Office makes all minor revisions, as defined by this policy, and submits the revised Policy to OC&E for verification and posting to the Policy Library.
     If only minor revisions are made during the triennial review, then the revision date will be updated; however, if the minor revisions occur off-cycle then the revision date will remain consistent with the triennial review schedule.
   • Substantive revisions: If substantive revisions are necessary, a full review of the draft Policy is required. The Responsible Office is required to follow the Review, Final Approval, and Implementation Phase procedures noted in §V.A.4, §V.A.5 and §V.A.6 of this policy.   The Executive Summary shall consist of the rationale for the substantive changes.
3. Retiring a policy: When a Responsible Office, in consultation with the ELT member with oversight of the Responsible Office, determines that a Policy is obsolete, the Policy’s retirement may be considered as provided below.
   • Retirement of an Administrative Policy requires approval by the ELT member with oversight of the Responsible Office.
   • Retirement of a BOV Policy requires approval by the ELT and BOV. The BOV reserves the right to delegate this to the ELT.
   • OC&E will remove the retired policy from the Policy Library and take responsibility for document retention.
   • The Responsible Office shall communicate the retirement of the Policy to the whole university community through the W&M Digest and Student Happenings. 

C. Local Policies

If a Responsible Office identifies a need for a Policy applicable only to an individual unit or units within the university, the Responsible Office or Policy owner should consult with OC&E to ensure the appropriate classification as a Local Policy and consider any related university Policies.

Local Policies that conflict with an Administrative Policy shall have no effect.  Responsible Offices are encouraged to follow the relevant procedures above to draft, implement, and maintain a Local Policy, including acquiring approval from the ELT member or designee with appropriate oversight.

D. Interim Policy Status 

This status is to be used sparingly and in the most urgent of situations so as to provide great deference to this process in support of shared governance. In cases of urgent need, such as when required by accreditation, legal, regulatory, or remedial actions a Responsible Office may acquire interim approval from the ELT to implement an Administrative or BOV Policy, whether the situation calls for a new Policy or Substantive Revisions to existing policy. To acquire interim approval, the Responsible Office must have the interim draft reviewed by OC&E and University Counsel, then acquire ELT’s final approval.
 
Within one (1) year of the approval as an Interim Policy, the Responsible Office must complete all required policy making procedures outlined herein to make the Interim Policy final. If a Responsible Office fails to acquire such approval within one (1) year, the policy may be removed from the university policy library and be deemed ineffective or the substantive changes may be removed and the previously approved version of the policy will become active again. The ELT reserves the right to extend this term.

VI. Enforcement; Complaints, Grievances or Appeals

This policy is enforced by OC&E and the University Policy Work Group. Noncompliance with this policy shall be referred to the ELT member with oversight of the Responsible Office and may result in disciplinary action up to and including termination. William & Mary supports an environment free from retaliation. Retaliation against any employee who brings forth a good faith concern, asks a clarifying question, or participates in an investigation is prohibited. 

VII. Authority & Amendment, Implementation

This policy is approved by President on January 29, 2020.

This policy was amended on February 23, 2026, to change approval from the ELT to the ELT member with oversight of the Responsible Office with awareness to the ELT of the creation or substantive changes to existing Administrative Policy prior to final approval. This policy was also amended to include the required review by the University Policy Work Group

VIII. Related Documents

William & Mary Policy Template (docx)