policy and procedures assignment of responsibilities

Master Writing Policies, Procedures, Processes, and Work Instructions

By Kate Eby | June 1, 2018 (updated July 19, 2021)

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Creating policies and procedures, as well as process documents and work instructions, can take months of research and writing. But, consider this: Well-crafted policies and procedures can help your organization with compliance and provide a structure for meeting and overcoming challenges, both big and small.

This article provides you with guidance on how to prepare for, research, write, review, and publish policies, procedures, and work instructions to get the best result for all stakeholders. Experts discuss the unique roles of each document in an organization, and downloadable checklists supply you with detailed guidance for the document creation process.

What Is Meant by Policies and Procedures?

While the terms are frequently mentioned together, policies and procedures serve different roles. Policies are high-level guidelines that define the culture of an organization by shaping decisions and providing a framework for daily activities. Procedures, on the other hand, enumerate lower-level processes and provide steps your employees need to take to adhere to your policies or complete a process. Together, they can guide an organization to success through legal and regulatory compliance.

Charles Cox is a Principal at Firefly Consulting , an Austin-based boutique consulting firm that specializes in innovation and operational excellence. He is also a featured contributor to the recent book Innovating Lean Six Sigma (McGraw-Hill, 2016). He describes how policies are “at a high level in the organization and almost never linked to a given part of operations. They provide an umbrella under which the entire organization operates. They key into what the organization is all about. Policy links to strategy, to culture, to decision making, whereas procedures and processes or work instructions are the actual documents that govern the transformation of inputs into outputs.”

What Are Company Policies and Procedures?

Policies and procedures in a company serve to define how employees are expected to behave and to detail responsibilities of both management and employees. Company policies and procedures help to ensure that employees receive their legal and ethical entitlements. At the same time, they guarantee that an organization pays proper attention to business concerns.

Why Do We Need Policies and Procedures in the Workplace?

Policies clarify the expected behavior and output of employees — or volunteers and others, such as board members — in the context of a specific organization, which allows employers and other leaders to manage more effectively. Policies and procedures guide daily workplace activities by promoting compliance with laws and regulations, providing strategic perspective for decision making, and simplifying processes.

How Do You Formulate or Write a Policy?

Creating good policies takes time and effort, but you can increase your chances for success by remembering a few basics. Most of the work happens before you ever begin to write. Your pre-writing activities include deciding on a document focus and researching background. After writing, your documents should be reviewed, validated, and approved. Finally, you will disseminate your documents and train users in the new policies and procedures.

Before you start to write, keep the following things in mind. A policy or procedure should focus on one concept at a time. Because of the complexity and effort required to develop good policies, and because they influence the values of your office and potentially also have legal ramifications, ensure that your C-level team supports and endorses your efforts. Support the policy with employee education. Don’t expect users to simply read and retain information. As you train, give users a positive reason for learning and adapting to any new guidelines, such as achieving greater efficiency (which leads to a better organizational bottomline).

Policy Procedure Creation Workflow

To get an overview of the policy creation process, follow this workflow, and then review the checklists for each step to ensure that you’ve covered all aspects.

Download Policy Procedure Creation Workflow

Basic Policy Procedure Template

You can also use this pre-formatted template to a policy. Simply add your logo and the specific content of your policy, and customize the sections in the template to fit your needs.

‌ Download Basic Policy Procedure Template

Policy and Procedure Pre-Writing Checklist

Much of the effort in creating policies and procedures takes place before you begin to write. This pre-writing checklist can help you find the support you need for your formal documents.

‌ Download the Policy and Procedure Pre-Writing Checklist

Policy and Procedure Research Checklist

The key to strong policies and procedures is understanding how the people who use the documents actually perform the documented activities. Use this research checklist to gather the resources needed for a document people will want to use.

‌ Download the Policy and Procedure Research Checklist

Policy and Procedure Writing Checklist

Once you have completed your pre-writing activities, this checklist can help you compose your policies and procedures clearly and efficiently.

‌ Download the Policy and Procedure Writing Checklist

Policy and Procedure Review and Approval Checklist

In most organizations, policies and procedures must receive written approval. Download this checklist to streamline the document approval process.

‌ Download the Policy and Procedure Review and Approval Checklist

Policy and Procedure Implementation Checklist

No matter how well-written or beautifully designed the document, you can’t just toss your new policies and procedures to the teams and expect them to read and understand everything. This checklist shows you how to present new policies and procedures for a lasting effect.

‌ Download the Policy and Procedure Implementation Checklist

What Fields Can Benefit from Policies and Procedures?

Every industry, business, and organization of any size, whether for-profit or nonprofit, government or private, regulated or non-regulated, can benefit from policies and procedures. The following are some of the fields that particularly benefit from defined policies and procedures:

• HR: HR provides many of the policies that are necessary in an organization. Examples include a clear termination policy, anti-discrimination policy, and time-off policy.
• Office Management: Examples of office policies include after-hours calls, petty cash access, and supply cabinet access.
• Law Enforcement and Emergency Services: Examples include the body camera policy, drone policy, and emergency communication policy.
• Construction: Examples include the orientation and training policy, refusal of work (when employees believe a situation is unsafe) policy, and time-reporting policy.
• Education: Examples include the code of ethics policy, tenure policy, and credit-hour policy.
• Healthcare: Examples include the cell phone policy for provider offices, appointment policy, and notice of non-discrimination in health insurance policy.
• Nonprofits: These include insurance for volunteers, recruitment and selection, and expenses.

Why Does a Company Have Policies and Procedures?

Companies implement policies and procedures for a number of reasons. As Cox explains, “Any company needs to have policies which address points of conflict before they happen.” Examples include points of hand off between teams, such as when designs are transferred to manufacturing. Policies also promote conflict resolution. “Many companies have escalation procedures, but that’s after the fact,” says Cox. “A proactive stance is better.”

They communicate internally the values, objectives, requirements, and best practices throughout the company, from the C-level to independent contractors. Policies in particular also communicate the company values and objectives to potential employees, investors, customers, and the media. In general, when executed correctly, policies and procedures serve to bring order where chaos could reign. Here is why policies and procedures are crucial to your organization:

• Policies and procedures help employees maintain compliance and mitigate or even eliminate risks.
• In a regulated industry, they demonstrate legal and regulatory compliance.
• Policies provide a means to change your company culture.
• Creating policies and procedures requires spending in dollars and work hours, but what is the cost of a process failure, an injury, or damaged property ?

Characteristics of Good Policies and Procedures

How do you get the best policy and procedure for your situation? Documents must meet your needs. A template can guide you to consider needed content and usable formatting, but the words and format must be customized to your situation. Following these guidelines, good documents provide the following:

• Ensure Compliance: If your organization is regulated, policies and procedures provide one means of proof that you’ve considered and implemented controls on activities.
• Increase Accountability, Training, and Responsibility: Applied correctly, policies and procedures can provide a structure for continual improvement.
• Streamline Internal Processes: Ideally, the best processes should be captured, and these provide the most efficient path for day-to-day activities.
• Help Organizations Avoid Errors and Maneuver Through Incidents and Problems: Good policies and procedures proactively anticipate problems and provide a structure for avoiding troubles or dealing with an immediate problem.

Suggested Basic Policies and Procedures

Specific policies and procedures may vary depending on the type of organization. At a minimum, you need policies for events, such as holidays or family emergencies, policies for behavior, such as attendance, absences, and harassment, and a policy governing technology, such as a BYOD policy. The table below shows some of the types of policies needed for three sample industries.

Pitfalls of Policies and Procedures

Certainly, establishing a consistent, efficient, and effective way of doing things is desirable, and policies and procedures can help. But, documents have their limits.

Andy Nichols is a Quality Program Manager at the  Michigan Manufacturing Technology Center . He sees a historical precedent for over-documentation rooted in the pre- ISO 9000  days of military procurement, when government agencies required any type of professionally formatted document that recorded repeatable processes. The original ISO, however, only called for a quality document that provided an umbrella for the entire organization. “Over-documentation was a perception of the standard. It was never prescribed at all,” says Nichols.

This misperception led to the brick-like documents that people still dread — multiple policies with a procedure to match each, often labeled with a number instead of a real-language title and with usable content buried at the lowest layer. “A lot of people never get past the idea that documentation doesn’t make things happen,” notes Nichols. In his opinion, “Trainers and consultants still espouse a structure that wasn’t necessary and caused a bureaucracy that got in the way of people adopting a quality system.”

Nevertheless, Nichols sees a role for documentation beyond process control. Procedures and work instructions in particular can capture knowledge and real-world experience to be passed on to the next generation. In manufacturing, that institutional memory element becomes especially crucial as seasoned workers retire. “Whatever the document type,” he says, “documents are an excellent way of capturing tribal knowledge.”

Companies with Progressive Policies

Progressive company policies include such things as allowing access to personal social media during office hours, permitting work from home or remote work access , or offering paid time off (i.e., a personal pool of days off to be used for sick days or other issues as needed). Another example, demonstrated by the following companies, is generous paid maternity leave, including, of course, adoptive or foster children.

• Ironworkers: Up to six months of paid maternity leave for female employees before the birth of a baby
• Etsy: Up to six months paid parental leave for the birth of a baby
• IKEA: Up to four months paid parental leave, including for adoptive and foster parents
• Starbucks: Paid maternity and paternity leave for everyone
• Adobe: Up to four months of paid time off for the primary caregiver after a birth or time off for either parent of a newly adopted, fostered, or surrogate child  
• Google: Up to 18 weeks of leave for the birth mother, extending to 22 weeks after a complicated birth. Up to 12 weeks of paid leave for primary caregivers of either gender for adoptions, fosters, and surrogate children. Seven weeks for non-primary caregivers.
• Microsoft: Three months paid parental leave, in addition to two more months for birth mothers
• Twitter: Up to five months of paid leave for birth mothers and 10 weeks for fathers
• Spotify: Up to six months of paid parental leave for all full-time employees
• Netflix: Unlimited paid leave for the first year after a birth or adoption
• Facebook: Up to 17 weeks of paid parental leave
• Reddit: Up to 17 weeks of paid parental leave

What Are the Policies and Procedures in a Childcare Setting?

Facilities supporting underage persons require their own set of documents. At a minimum, the following policies and procedures apply:

• Establishment code of conduct
• Child safety
• Operating schedule
• Parent handbook
• Employee handbook
• Disaster and emergency procedure
• Proof of national accreditation

What Are the Policies and Procedures in Health and Social Care?

Health and social care policies include guidelines to protect the health and safety of healthcare workers. They also provide standards for vulnerable citizens, such as guidelines for their healthcare, food safety in facilities, living conditions in facilities or domicile care, general safety and security, and well-being and protection during civil emergencies, such as pandemic, earthquake, or severe weather events.

Common Elements of Policies and Procedures

Although it is important to customize any documents for your situation, policy and procedure documents tend to include core elements that help identify the document and provide the information necessary:

• Clear Title: Use as few words as possible and ensure that users at any reading level can understand.
• Brief Description of the Policy: A description or introduction orients users to the scope and purpose of the policy.
• A Filing Number: A filing or tracking number may be unique to your organization. No matter what your numbering system, ensure that your title describes the content of the document.
• Key Dates: Dates include the approval date of the original document, the annual review date, and the latest version date. Dates are important for tracking versions around legislative and other updates.
• Policy Purpose: The purpose describes why the policy exists. This includes such concerns as legal and regulatory needs and problems or conflicts a policy aims to avoid.
• Policy Statement: The core of the document and usually the lengthiest part. The policy statements specify the main audience for the policy, conditions and restrictions for applying the policy, expectations, and exclusions.
• Scope: This concerns which roles or departments the policy covers.
• Responsibilities or Responsible Party: Indicate what role, department, or group must maintain the policy. Alternatively, for some policies governed by regulations, this section lists roles responsible for executing the policy.
• Definitions: Describe key terms, jargon, or ambiguous terms. Always explain key terms in a separate definitions section or at first mention in the text of your policy or procedure to ensure that everyone has the same understanding of terms. Definitions are particularly important for terms that may have multiple meanings.
• History: Knowing the history is useful for understanding changes.
• Related Documents: Attach other policies, procedures, regulatory documents, forms, and guidelines for reference.
• Search Functionality: For web-based documents, this is a policy search feature.
• Keywords: For online documents, choose keywords that relate to how a user might search for your policy.

Tools and Considerations for Creating a Policy and Procedure

If your organization must create many policies and procedures, consider purchasing a purpose-built policy management platform. Such software provides templates and a central hub for drafting, reviewing, and publishing documentation and built-in version control. Some programs also offer self-training capability, which includes recordkeeping for grades in quizzes. This is important for compliance audits.

Manual template packages are also available for sale, sometimes with software. Policy management plugins provide policy document management for common collaboration platforms. If documents are created in a word processing program, migrating them to a central location is of greater significance. Many organizations provide a web portal for policies and procedures, where users can easily search on keywords for the desired content.

No matter how the documents are created, online publishing options help to ensure that users can easily access the latest version. Binders of documents that no one can find have never been helpful.

How Do You Write a Procedure?

Many of the steps for preparing policies are echoed in the preparation of procedures. For procedures, the need to understand the process is of particular importance. When writing a procedure, keep the following things in mind:

• Decide what task needs to be detailed.
• Get background and context for each procedure.
• Observe employees in day-to-day tasks to understand current procedures.
• Interview employees who perform the tasks. You can increase their interest in and engagement with documentation by including the relevant employees during the writing process.
• Look through the audit history to understand if procedures require an update in response to non-compliance or a safety event. Recording incidents, investigating how they occurred, fixing the problem, and then regularly training and making improvements is the basis of corrective and preventive action (CAPA) .
• Validate procedures in a walkthrough to ensure that users can follow them adequately.
• Ensure that wording and intent in procedures aligns with related policies, procedures, and other documents, such as forms or diagrams.

How Do You Write a Work Instruction?

Even more so than with procedures, if work instructions form part of your documentation, they must be precise and written in the users’ language. Work instructions must be specific about how a task is completed. Visual cues help learners with marginal or no reading skills, and graphics aid all users to more easily grasp and retain concepts. Keep the following things in mind when writing work instructions:

Work instructions may consist of only bullet points. Text must be scannable with clear headings.

Work instructions may include only pictures and numbers.

Some software packages for manufacturing add animation and 3D capability to help process engineers and shop floor workers better visualize instructions.

Document management systems enable reuse of validated procedures and instructions that are common to many activities, which eliminates the need to rewrite steps and the possibility of introducing ambiguities.

Language, Tone, and Style in Policies and Procedures

It’s important to write clearly, concisely, and simply. To help you achieve this, write with the reader in mind and follow these tips:

• Write to the reading level of the document users. If necessary, use only numbers, graphics, and photographs.
• Use short sentences with familiar English words and one thought or concept per sentence.
• Use must or will if something is mandatory. Avoid ambiguous words such as may or shall.
• Use plain words that are commonly understood rather than jargon. If you must use specialized terms, explain them in the text and in your glossary section.
• Use terms consistently throughout your documents.
• Write the full name for acronyms when you first use them.
• Remove extra words. For example, use to instead of in order to.
• Use positive and inclusive language. Use gender-neutral terms, such as their, not he or she, and worker, not workman.
• Use active voice rather than passive voice. For example, You must wash the dishes (active) rather than The dishes must be washed (passive).
• Use present tense. For example, say When you finish your shift, you lock the cabinets.
• Use headings that clearly identify the content of each section.
• Use evergreen information. For example, use [email protected] rather than contact information for a specific individual whose contact information may change.

Download this document with tips on tone to maximize the effectiveness and readability of your policies and procedures.

‌ Download Policy and Procedure Tone Tips

Formatting for Finding Information Fast

In addition to writing clearly, you can enhance the usability of your policies and procedures with a clear layout and optimal use of color and graphics, such as charts, diagrams, and images. Many fields and regulatory areas have predefined templates that can expedite your writing process by showing the types of content you must add. Templates usually also provide an attractive, readable format, so you don’t have to worry about layout and design. You can customize the content to suit your organization.

Here are some other formatting tips:

• Include a table of contents in Word or PDF format or with hyperlinks if online.
• Name the document clearly, so users can easily identify its purpose.
• Organize the material logically and label sections clearly, so readers can easily find the content they need.
• Make sure the links to the document from other documents and from other websites are working and up to date.
• Break the text into chunks to aid panning and scanning — include bulleted and numbered lists, graphics, charts, diagrams, well-written headings, and numbered paragraphs.
• Order topics and sections logically and use clear headings.
• Consider numbered paragraphs, which make content easier to locate in lengthy documents. However, limit organization to three levels. The first level is numbered 1, 2, 3; the second level is 1.1, 1.2, 1.3; the third level is 1.1.1, 1.1.2, 1.1.3.
• Numbered drawings and photos may convey more information than words do and may be best for certain situations.
• Use white space to avoid crowded text.
• Templates tend to have predefined sections and often subdivide sections, which can aid users in quickly finding the information they need.
• Consider using icons and colors to designate specific elements, for example, blue for links and red for caution.

If you have the a designer who can help you create icons or choose existing ones, these symbols can help direct users to appropriate sections of your documents.

Packaging Policies and Procedures

Although policies and procedures serve different purposes, they can be combined in one document, particularly when both the policies and accompanying procedures are short. Some believe, however, that their different roles are a good reason to separate then into two documents. Ideally, you should update procedures (and especially work instructions) frequently to reflect innovations in process or address problems and incidents. You can revise policies less frequently.

What Is the Difference between a Policy and a Procedure and a Process and a Work Instruction?

To have an efficient and compliant organization, you need all three p documents — policies, procedures, and processes — plus something else: work instructions. The terms policy and procedure are sometimes confused and used interchangeably, whereas they serve different purposes.

• Policy: Policies are the guidelines that oversee organization activities, such as green manufacturing or a smoke-free environment. Policies describe legal, regulatory, or internal standards for required behavior and activities. Policies and procedures, depending on the size of the organization, may fill a volume or more or may consist of simply a handful of short paragraphs. Cox sees policies as “more shades of grey,” as guidelines that senior and middle management use. “Policies require a lot of interaction between the senior leadership team and upper middle management,” he explains. “Policies need to be reviewed every so often to make sure they are serving the needs of the organization and require flexibility around them for revisions,” he adds. As they define company culture, policies also communicate strategy, such as green manufacturing. Policies help reduce risk and ideally create an environment that encourages improvement. Although policies may reference laws and regulations, they do not reiterate laws and standards. Instead, they define a particular application of those legal or regulatory guidelines. 
• Procedures: Procedures guide middle management and create overarching structure for process instructions and work instructions, which provide production tasks and steps for supervisors, individual contributors, and workers. Procedures are used by supervisors, industrial engineers, or the individual worker. Procedures describe the process at a higher level and may be in a binder. They depict a repetitive task or process. In manufacturing, procedures describe a series of steps or tasks and contain work instructions. In general, procedures describe what to do, when to do something, and who does it. “Procedures are very specific and need to be very black and white without a lot of need for interpretation,” says Cox. But, while the content may provide precise descriptions, the descriptions may change more frequently. “At the work instruction level, they may change every day or every few days as they [employees] attempt to get the best result for the customer.”
• Processes: Processes describe what the organization does and who does it. They explain how procedures fit together to create deliverables or accomplish goals and objectives.
• Work Instructions: Work instructions are the lowest level of document used by supervisors, individual contributors, or workers, with descriptions of how to complete a specific step. Work instructions are granular, short documents, often of only one page, a single paragraph, or a set of bullet points, and frequently include many visual cues, such as colors, graphics, or photographs. Work instructions are intended to be precise documents that allow interchangeable staff in high turnover situations to train and achieve optimum performance in one hour or less. As Cox describes them, “Work instructions provide what is necessary to train a person as fast as possible or even self-training.” These documents should be at the worksite, so the trainer, and eventually the worker, can refer to them. An essential part of work instructions are checklists, which he says can be as simple as a photo with items of interest circled.

‌ Download Policy and Procedure Process Work Instruction Checklist

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Step-by-Step Guide: How to Write a Policy and Procedure Manual

• Employee Handbooks
• September 11, 2023

A well-written policy and procedure manual is an essential tool for every organization, providing clear guidelines and instructions for employees to follow. This step-by-step guide will walk you through the process of creating a comprehensive manual that is effective and easy to understand. Before diving into the guide, let’s first explore the benefits of having a policy and procedure manual and understand its key components.

Having a policy and procedure manual brings numerous advantages to an organization. It ensures consistency in decision-making, promotes compliance with laws and regulations, improves employee performance and accountability, enhances communication and transparency, and helps mitigate risks and conflicts.

To create a cohesive and structured manual, it is important to include key components such as a title and table of contents, an introduction and purpose statement, organizational structure and responsibilities, policies, procedures, forms and templates, a glossary of terms, and a version control and review process.

Now, let’s dive into the step-by-step guide on how to write a policy and procedure manual. This guide will cover crucial aspects such as determining the scope and objectives, involving stakeholders, researching relevant laws and regulations, creating an outline and structure, writing clear and concise policies, developing detailed procedures, including necessary forms and templates, reviewing and refining the manual, obtaining approval, and finally, publishing the manual.

As you embark on this journey of creating a policy and procedure manual, keep in mind a few tips for an effective manual. These tips include using clear and simple language, organizing information logically, using visuals and examples where necessary, ensuring the manual is easily accessible and regularly updated, and providing training and support for employees to understand and implement policies and procedures effectively.

By following this step-by-step guide and incorporating these tips, you can create a well-crafted policy and procedure manual that serves as a valuable resource for your organization, bringing clarity, consistency, and efficiency to your operations.

Benefits of Having a Policy and Procedure Manual

A policy and procedure manual provides several key benefits for an organization:

• Consistency: A manual ensures consistency in how policies and procedures are implemented across different departments or branches of an organization. This helps maintain a unified approach and ensures fairness and equity.
• Clarity: Having a manual clarifies expectations for employees regarding their roles, responsibilities, and conduct. It provides clear guidelines on how to handle various situations, reducing ambiguity and potential misunderstandings.
• Efficiency: A well-written manual streamlines processes and procedures, leading to increased efficiency and productivity. Employees can easily access the information they need, saving time and minimizing errors.
• Training and Onboarding: A policy and procedure manual serves as a valuable resource for training new employees. It provides them with a comprehensive overview of the organization’s policies, procedures, and standards, ensuring a smooth onboarding process.
• Compliance: A manual helps organizations comply with legal and regulatory requirements. It ensures that policies and procedures align with industry standards and guidelines, reducing the risk of non-compliance and potential legal issues.
• Consolidated Information: By consolidating all policies and procedures in one document, a manual simplifies the management and dissemination of information. It becomes the go-to resource for employees, minimizing the need for multiple documents or sources of information.
• Conservation of Knowledge: A policy and procedure manual serves as a repository of institutional knowledge. It ensures that important information is documented and can be accessed by current and future employees, preventing knowledge loss due to employee turnover.
• Communication: A manual facilitates effective communication within an organization. It establishes a common language and understanding of policies and procedures, enabling employees to communicate more efficiently and effectively.
• Accountability: Having documented policies and procedures promotes accountability at all levels of the organization. It provides a basis for evaluating employee performance and ensuring adherence to established guidelines.
• Continuous Improvement: A policy and procedure manual can be regularly reviewed and updated to reflect evolving best practices, industry standards, and changes within the organization. This promotes a culture of continuous improvement and adaptability.

Key Components of a Policy and Procedure Manual

Now that we are clear on the benefits of writing a policy and procedure manual for your organization, now it time to learn how to write a policy and procedure document. When creating a policy and procedure manual, it’s crucial to understand the key components that make it comprehensive and effective . In this section, we’ll explore the essential elements that should be included in your manual. From the title and table of contents to the glossary of terms , each sub-section plays a vital role in providing clear guidance and structure . Let’s dive in and discover how these components contribute to a well-crafted policy and procedure manual .

1. Title and Table of Contents

Here is an example of a table of contents:

Each section in the table of contents serves a specific purpose in the manual and allows readers to quickly find the information they need. It is important to ensure that the table of contents accurately reflects the content of the manual and is updated whenever new sections or revisions are made.

2. Introduction and Purpose Statement

The introduction and purpose statement play a crucial role in the policy and procedure manual. They establish the context and objectives of the document, providing a solid foundation. The introduction gives an overview of the manual, emphasizing its importance in creating a standardized framework for organizational operations . It serves as a guide for employees , managers , and stakeholders to understand the organization’s policies , procedures , and responsibilities .

The purpose statement further strengthens the manual’s intent by specifying its goals and intended outcomes. It clearly communicates the reasons behind creating the manual and what it aims to achieve. This statement should be concise and straightforward, highlighting the key objectives that the manual will address.

Incorporating the introduction and purpose statement enhances the value and usefulness of the policy and procedure manual. It ensures that readers grasp the document’s intended function and the rationale behind its implementation. By expressing the goals and objectives clearly, organizations can foster a culture of compliance, efficiency, and consistency.

A well-crafted introduction and purpose statement establish a solid foundation for effective communication and implementation of the organization’s policies, procedures, and guidelines. They provide a clear starting point for employees, managers, and stakeholders to navigate the manual and understand its essential components.

3. Organizational Structure and Responsibilities

When it comes to creating a policy and procedure manual, establishing a clear organizational structure and defining responsibilities are crucial. This ensures that everyone in the organization knows their role and responsibilities, resulting in efficient operations and streamlined decision-making processes.

• Designate clear roles: Define the various positions within the organization and outline the responsibilities of each role. This includes identifying leaders, managers, and team members, and specifying their areas of expertise.
• Establish reporting lines: Clearly outline the hierarchy and reporting structure within the organization. This includes defining who reports to whom, ensuring accountability, and facilitating effective communication.
• Define decision-making authority: Clearly outline the decision-making processes and levels of authority within the organization. Specify who has the authority to make certain types of decisions, ensuring that decisions are made by the appropriate individuals based on their expertise and responsibilities.
• Create job descriptions: Develop detailed job descriptions for each role, describing the specific tasks, responsibilities, and qualifications required for each position. This helps ensure clarity and alignment in expectations and performance standards.
• Allocate resources effectively: Clearly define the resources, such as budget, personnel, and equipment, that are available to each role. This helps individuals understand what is available to them in order to fulfill their responsibilities effectively.

By establishing a clear organizational structure and defining responsibilities, organizations can promote collaboration, efficiency, and accountability. This ensures that everyone understands their role and can effectively contribute to the goals and objectives of the organization.

4. Policies

When developing policies for your policy and procedure manual, it is important to follow a step-by-step approach to ensure clarity and effectiveness. Here is a list of steps to consider:

• Identify the areas or topics that require policies.
• Conduct thorough research and gather information on best practices , industry regulations , and legal requirements .
• Clearly define the purpose and objectives of each policy.
• Use language that is clear, concise, and easy to understand.
• Include specific guidelines, procedures, and expectations within each policy.
• Ensure that policies are aligned with organizational goals and values .
• Consider the impact of the policies on different stakeholders and involve them in the policy development process.
• Review and revise policies regularly to keep them up to date and relevant.
• Obtain approval from relevant authorities, such as management or a board of directors , before finalizing and publishing the policies.

Following these policies development steps will help you develop comprehensive policies that address the specific needs of your organization and ensure compliance with legal requirements. It is also important to regularly review and update policies to adapt to changes in the industry or organization.

5. Procedures

When crafting the procedures section of a policy and procedure manual, it’s essential to follow a structured approach that aligns with your organization’s objectives. Begin by referring to any provided policy and procedure template , as it serves as the foundational framework for documenting and implementing these processes.

In this section, each procedure should be outlined in a clear and concise manner, detailing the step-by-step actions, responsibilities, and timelines to ensure consistency and compliance with the established policies. Furthermore, always remember to review and update this section periodically to reflect any changes in your business operations or regulations, ensuring its ongoing relevance and effectiveness.

6. Forms and Templates

When creating a policy and procedure manual, one important component to include is forms and templates . These forms and templates serve as standardized documents that can be used to streamline processes and ensure consistency within an organization.

Forms are documents that collect information or facilitate specific actions within a process. For example, an employee evaluation form can be used to assess an employee’s performance and provide feedback. Templates , on the other hand, are pre-designed documents that can be customized for specific purposes. A template can be used for creating a meeting agenda or a memo.

By including forms and templates in a policy and procedure manual, organizations can save time and effort by providing employees with ready-to-use documents. This can help eliminate confusion and ensure that processes are carried out effectively and efficiently.

Forms and templates can enhance compliance with regulatory requirements. By providing standardized forms , organizations can ensure that necessary information is collected accurately and consistently.

It is important to regularly review and update forms and templates to ensure they remain current and relevant. This can be done as part of the manual’s review and refinement process.

Pro-tip: Consider creating electronic versions of forms and templates to allow for easy editing and distribution. This can further streamline processes and promote efficiency within the organization.

7. Glossary of Terms

When it comes to policy and procedure manuals, having a glossary of terms is essential in ensuring clarity and understanding. The glossary serves as a reference for key terms used throughout the manual, providing concise definitions to aid readers in comprehending the content.

Having a comprehensive glossary of terms ensures that individuals reading the policy and procedure manual can easily understand the terminology used and interpret the content correctly. This promotes consistency in communication and reduces the likelihood of misinterpretation or confusion.

To create an effective glossary of terms, it is important to review and update it regularly to reflect any changes or additions to the terms used in the manual. The definitions should be concise and clear, avoiding technical jargon or ambiguity.

8. Version Control and Review Process

When it comes to creating a policy and procedure manual, version control and the review process are crucial for maintaining accuracy and effectiveness. Here are some key aspects to consider:

• Implement a clear and organized system for tracking different versions of the manual. Utilize numerical or alphanumeric identifiers to differentiate between versions, such as “Version 1.0,” “Version 2.0,” and so on. This allows for easy reference and ensures that everyone is working with the most up-to-date information.
• Designate individuals or a review committee responsible for regularly reviewing the policy and procedure manual. This ensures that any necessary updates or changes are identified and implemented in a timely manner. It is essential to involve subject matter experts and key stakeholders to ensure accuracy and relevance.
• Establish specific review periods and timelines to ensure the manual is regularly evaluated and updated as needed. This could be monthly, quarterly, or annually, depending on the nature of the organization and the frequency of changes in policies and procedures.
• During the review process, keep a record of any identified issues, updates, or revisions that need to be made. This documentation ensures that changes are properly tracked and implemented in subsequent versions of the manual.
• Once a review is complete and revisions have been made, ensure that all relevant stakeholders are informed of the changes . This can be done through email notifications, training sessions, or by publishing the updated manual in a central location accessible to all employees.

By implementing a robust version control and review process, organizations can ensure that their policy and procedure manuals remain accurate, current, and aligned with their goals and objectives.

Remember, maintaining version control and conducting regular reviews is essential to the overall effectiveness and usefulness of the policy and procedure manual.

Step-by-Step Guide to Writing a Policy and Procedure Manual

Crafting a comprehensive policy and procedure manual may seem like a daunting task, but fear not! In this guide, we’ll walk you through the step-by-step process of creating an effective manual that meets your organization’s needs. From defining the scope and objectives (Step 1) to obtaining approval and publishing the final manual (Step 9), each sub-section will provide valuable insights and practical tips to ensure your manual is clear, concise, and aligned with relevant laws and regulations. So, let’s dive in and unlock the secrets to writing a rock-solid policy and procedure manual!

Step 1: Determine the Scope and Objectives

When creating a policy and procedure manual, Step 1 is to determine the scope and objectives of the manual. This is crucial as it sets the foundation for the entire document and ensures that it aligns with the organization’s goals and values.

• Identify the areas of the organization that will be covered by the manual. This could be specific departments, functions, or processes.
• Clearly define the objectives of the manual . What do you hope to achieve by implementing these policies and procedures? Is it to enhance efficiency, ensure compliance, or improve customer satisfaction?
• Consider the legal and regulatory requirements that need to be addressed. Are there specific laws or regulations that the organization must adhere to? This will help determine the scope and depth of the manual.
• Identify any specific challenges or issues that the organization faces and that the manual should address. This could include safety concerns, ethical considerations, or industry-specific requirements.
• Involve key stakeholders in the process of determining the scope and objectives. This could include managers, employees, and legal or compliance experts. Their input and expertise will ensure that the manual is comprehensive and relevant.
• Once the scope and objectives have been determined, clearly communicate them to all employees. This will help create a shared understanding of the purpose and importance of the manual.

In the early 20th century, as organizations began to grow and become more complex, the need for clear policies and procedures became evident. The first recorded policy and procedure manuals were developed by the military, aiming to standardize operations and ensure consistency. Over time, the practice spread to other industries, and today, policy and procedure manuals are considered essential documents for effective organizational management.

Step 2: Identify Stakeholders and Involve Them

When writing a policy and procedure manual, it is crucial to Identify Stakeholders and Involve Them . This step ensures that the manual addresses the needs and requirements of all relevant parties. Below is a comprehensive list of steps to guide you:

• Identify the key stakeholders: Determine the individuals or groups affected by the policies and procedures outlined in the manual. This can include employees, managers, executives, as well as external parties like customers or regulatory agencies.
• Involve stakeholders in the process: Engage the identified stakeholders and actively seek their input and feedback. Various methods can be employed, such as surveys, focus groups, interviews, or meetings. Emphasize open and transparent communication to gather diverse perspectives.
• Determine their needs and expectations: Gain an understanding of the specific requirements, concerns, and priorities of the stakeholders. This knowledge will facilitate tailoring the policies and procedures to meet their unique needs.
• Collaborate on policy development: Collaborate with stakeholders to develop policies and procedures that align with their expectations. Brainstorming sessions, workshops, or collaborative document editing can be effective approaches.
• Seek consensus: Strive to achieve a consensus among the stakeholders regarding the final policies and procedures. Address any conflicting views or concerns through negotiation and compromise.
• Obtain approval: Once the policies and procedures have been developed collaboratively, seek approval from relevant parties, such as management or a governing board.
• Communicate the involvement: It is crucial to clearly communicate to the stakeholders that their input and involvement were considered and integrated into the manual. This promotes transparency and fosters a sense of ownership and buy-in.

By diligently following these steps, you will ensure that the policy and procedure manual reflects the needs and perspectives of stakeholders, enhancing its effectiveness in guiding organizational practices. Remember, Identifying Stakeholders and Involve Them is an indispensable part of this process.

Step 3: Research Relevant Laws, Regulations, and Best Practices

When writing a policy and procedure manual, it is important to thoroughly research relevant laws, regulations, and best practices to ensure that your manual is accurate, up-to-date, and compliant with legal requirements and best practices in your industry. Here are the steps to follow for conducting research on relevant laws, regulations, and best practices:

1. Identify the governing laws and regulations: Determine the specific laws and regulations that govern your industry or organization, including federal, state, and local laws, as well as industry-specific regulations.

2. Consult official sources: Research the official sources of the laws and regulations, such as government websites, legislative databases, and regulatory agencies. These sources provide the most accurate and current information on best practices.

3. Review industry guidelines and standards: Identify any industry-specific guidelines, standards, or best practices that apply to your organization. These may be set by professional associations or regulatory bodies within your industry.

4. Analyze case studies and precedents: Look for relevant case studies or legal precedents that can provide insights into how specific laws and regulations have been interpreted and applied in practice. This can help you understand the implications of certain rules and ensure compliance with best practices.

5. Consider international standards: If your organization operates internationally, research any applicable international standards or treaties that may impact your policies and procedures in order to align them with best practices.

6. Consult legal and industry experts: Seek advice from legal counsel or industry experts who are knowledgeable about the laws, regulations, and best practices relevant to your organization. They can provide valuable insights and help ensure the accuracy of your manual while adhering to best practices.

By following these steps and conducting thorough research, you can ensure that your policy and procedure manual is comprehensive, compliant, and aligned with the best practices in your industry.

Step 4: Create an Outline and Structure

Creating an outline and structure for a policy and procedure manual is a crucial Step 4 in the writing process. Here is a Step-by-Step Guide on how to accomplish this:

• Identify the major sections of the manual.
• Start with a title and table of contents to provide a clear organization of the content.
• Include an introduction and purpose statement to provide an overview of the manual’s objectives.
• Outline the organizational structure and responsibilities to establish the hierarchical framework.
• Define the policies that need to be included, ensuring they cover all relevant areas.
• Develop procedures for each policy, providing step-by-step instructions on how to implement them.
• Include any necessary forms and templates that need to be used in conjunction with the policies and procedures.
• Add a glossary of terms to clarify any specific terminology used throughout the manual.
• Incorporate a version control and review process to ensure the manual is regularly updated and improved.

By following these steps, you can create a well-organized policy and procedure manual that is easy to navigate and understand.

Fun Fact: The establishment of a clear outline and structure in a policy and procedure manual helps to streamline operations and promote consistency across an organization.

Step 5: Write Clear and Concise Policies

When writing clear and concise policies for a policy and procedure manual, it is crucial to follow a systematic approach. The following steps can guide you in effectively crafting policies:

• Identify the objective: Clearly define the purpose of the policy and what it aims to achieve. This helps in keeping the policy focused and relevant.
• Gather relevant information: Conduct thorough research on applicable laws, regulations, and best practices to ensure that the policies align with legal requirements and industry standards.
• Use plain language: Communicate policies in a simple and straightforward manner using clear and concise language. Avoid jargon or technical terms that may confuse readers.
• Structure policies appropriately: Organize policies into sections or categories, making them easy to navigate. Use headings, subheadings, and bullet points to provide clarity and enhance readability.
• Step 5: Write Clear and Concise Policies : Clearly state the purpose and scope of each policy. Define key terms and provide background information to help readers understand the policy’s context.
• Include specific guidelines: Clearly outline the actions or behaviors that are expected or prohibited. Provide specific instructions or examples to guide readers on how to comply with the policy.
• Consider exceptions and limitations: Acknowledge any exceptions or limitations to the policy and provide guidelines on how to handle such situations.
• Review for accuracy: Ensure that the policies are accurate, up-to-date, and aligned with any recent changes in laws or regulations. Regularly review and update policies as needed.
• Seek feedback: Before finalizing the policies, consider obtaining input and feedback from relevant stakeholders to ensure that the policies address their concerns and needs.

By following these steps, you can write clear and concise policies that effectively communicate expectations and guidelines to the users of the policy and procedure manual. Moreover, if you are provided a policy writing template , remember to tailor the policies to your organization’s specific needs and ensure that they are in line with applicable laws and regulations.

Step 6: Develop Detailed Procedures

Developing detailed procedures (step 6) is a crucial step in creating an effective policy and procedure manual. To ensure clarity and efficiency, follow these steps:

• Step 1: Review Policies: Familiarize yourself with the policies outlined in the manual. Understanding the policies will help you determine the specific procedures needed to implement them effectively.
• Step 2: Identify Objectives: Clearly define the objectives of each procedure. This will guide the development process and ensure that the procedures align with the overall goals of the organization.
• Step 3: Break it Down: Divide each procedure into clear and logical steps. Use bullet points or numbered lists to outline the sequence of actions required.
• Step 4: Include Specific Details: Provide specific instructions and guidelines in each step. Use action verbs and concise language to enhance clarity and comprehension.
• Step 5: Consider Risks and Contingencies: Anticipate potential risks or challenges that may arise during the execution of the procedure. Include alternative steps or contingency plans to mitigate these risks.
• Step 6: Ensure Consistency: Maintain a consistent format throughout the manual. This will make it easier for users to navigate and locate relevant procedures.
• Step 7: Seek Input: Collaborate with relevant stakeholders, such as employees or subject matter experts, to gather insights and refine the procedures. Their input will help ensure that the procedures are practical and effective.
• Step 8: Review and Revise: Regularly review and update the procedures to reflect any changes in policies, regulations, or best practices. This will help keep the manual up-to-date and relevant.
• Step 9: Test the Procedures: Before finalizing the manual, test the procedures in a real-life setting. This will allow you to identify any areas that need further clarification or improvement.

By following these steps, you can develop detailed procedures (step 6) that are clear, comprehensive, and aligned with the policies outlined in the policy and procedure manual.

Step 7: Include Appropriate Forms and Templates

When writing a policy and procedure manual, it is important to include appropriate forms and templates to ensure consistency and efficiency in processes and documentation. Here are the steps to follow for including these forms and templates:

• Identify the specific forms and templates needed for the policies and procedures outlined earlier in the manual.
• Ensure that the forms are aligned with the objectives and goals of the organization.
• Create or obtain the necessary forms and templates, including forms for incident reporting , employee performance evaluations , or equipment maintenance logs , among others.
• Carefully review each form and template to ensure that they are clear, concise, and user-friendly. Remove any unnecessary fields or sections.
• Format the forms and templates consistently throughout the manual to maintain a cohesive and professional look.
• Include instructions or guidelines on how to properly complete each form or template. This will help users understand the purpose and procedures associated with each document.
• Step 7: Include Appropriate Forms and Templates. Place the forms and templates in an accessible location within the manual. Consider using numbered sections or a separate appendix specifically dedicated to these documents.
• Regularly review and update the forms and templates as needed to reflect any changes in policies, procedures, or regulations.

By including appropriate forms and templates in the policy and procedure manual, organizations can ensure that employees have the necessary tools to consistently and accurately complete important documentation.

Step 8: Review and Refine the Manual

• Add a team of reviewers : Select a group of individuals who are knowledgeable and experienced in the subject matter to review the policy and procedure manual.
• Set a timeline: Allocate a specific timeframe for the review process to ensure that it is completed in a timely manner.
• Conduct a thorough examination : The reviewers should carefully read through the manual, paying attention to accuracy, clarity, and consistency.
• Check for compliance : Ensure that the policies and procedures outlined in the manual adhere to relevant laws, regulations, and best practices.
• Solicit feedback : Encourage the reviewers to provide constructive feedback and suggestions for improvement. This can be done through meetings, written comments, or an online feedback system.
• Revise and refine : Based on the feedback received, make necessary revisions to the manual. Clarify any ambiguities, correct errors, and streamline the content to enhance readability.
• Ensure consistency : Review the entire manual to ensure consistency in tone, language, formatting, and style. This will help maintain a professional and cohesive document.
• Update references : Cross-reference any external documents, regulations, or policies mentioned in the manual to ensure they are current and accurate.
• Finalize the manual : Once all revisions have been made, obtain approval from the appropriate stakeholders and publish the policy and procedure manual.

Step 9: Obtain Approval and Publish the Manual

• Create a draft of the policy and procedure manual , ensuring that each section is complete and well-written.
• Review the draft internally within the organization, involving key stakeholders such as department heads, managers, and legal advisors . Obtain their feedback and make necessary revisions.
• Once the draft is finalized, seek approval from higher management or the designated authority responsible for approving policies and procedures. This ensures that the manual aligns with the organization’s goals, values, and legal requirements.
• Before publishing, conduct a final review to ensure accuracy, consistency, and clarity . This includes reviewing the content, formatting, and language of the manual.
• Create a final version of the manual in the desired format, such as a printed document or an electronic file . Remember to include a cover page and a table of contents for easy navigation.
• Distribute the approved manual to all relevant stakeholders within the organization. This may include employees, managers, and other individuals who need access to the policies and procedures outlined in the manual.
• Consider providing training or orientation sessions to ensure that everyone understands the contents of the manual and their responsibilities in adhering to the policies and procedures.
• Make the manual easily accessible to all stakeholders , whether through an intranet, shared file system, or physical copies. This allows for easy reference and ensures that everyone has access to the most up-to-date version.
• Regularly review and update the manual as needed to reflect changes in policies, procedures, or regulations. Communicate any updates to stakeholders and ensure that they have access to the revised version.

Tips for Effective Policy and Procedure Manuals

Follow these tips to create an effective policy and procedure manual:

• Clear and Concise Language: Use clear and concise language to ensure that policies and procedures are easily understood by all employees.
• Organize Information: Organize policies and procedures in a logical manner, using headings, subheadings, and numbered sections. This helps employees navigate the manual and find information quickly.
• Use Visual Aids: Incorporate visual aids such as flowcharts, diagrams, or tables to enhance understanding and simplify complex processes.
• Provide Examples: Include examples or case studies to illustrate how policies and procedures should be implemented in real-life situations.
• Regular Updates: Policies and procedures should be reviewed and updated regularly to ensure they remain relevant and aligned with current practices and regulations.
• Employee Involvement: Involve employees in the development and review process to gather feedback and ensure that policies and procedures reflect the realities of the workplace.
• Accessibility: Ensure that the manual is easily accessible to all employees, whether in print or electronic format. Consider using an online platform or intranet to make it easily searchable.
• Training and Communication: Provide training to employees on how to use the manual effectively and communicate any updates or changes to policies and procedures.
• Consistency: Maintain consistency in language, formatting, and style throughout the manual to create a cohesive document.
• Legal Compliance: Ensure that policies and procedures comply with applicable laws, regulations, and industry standards.
• Regular Review: Regularly review the manual to identify any gaps, inconsistencies, or outdated information. Seek feedback from employees and make necessary revisions.
• Document Control: Implement a system for document control to keep track of versions, revisions, and approvals of policies and procedures.

By following these tips, you can create a comprehensive and user-friendly policy and procedure manual that effectively communicates important information to your employees.

Frequently Asked Questions

How do i write a comprehensive policy and procedure manual.

Writing a comprehensive policy and procedure manual involves following a step-by-step journey. Start by outlining the key policies and procedures that are essential for your organization. Then, gather information on employment procedures, workplace code of conduct, health and safety guidelines, communication policies, and other relevant topics. Organize the information in a structured internal document, ensuring it covers all necessary areas. Review and refine the manual for accuracy and clarity, and make sure it reflects your company’s culture and values. Finally, distribute the manual to all employees and provide training on its contents.

Why is it important to have a policies & procedures manual for virtual employees?

A policies & procedures manual serves as a reliable source of information for virtual employees. It acts as a one-stop location for them to access the company’s policies, procedures, and work standards. This ensures that virtual employees understand the expectations, guidelines, and protocols that they should follow while working remotely. It also provides constant assurance that the same policies and procedures apply to all employees, regardless of their location.

What should be included in a policies & procedures manual regarding employee benefits?

A policies & procedures manual should include comprehensive information about employee benefits. This may cover topics such as health insurance options, retirement plans, vacation and leave policies, and other perks and incentives offered by the company. Clear guidelines on how to avail these benefits, eligibility requirements, and any necessary documentation should also be included in the manual.

How can a policies & procedures manual contribute to maintaining a positive company culture?

A policies & procedures manual plays a crucial role in establishing and maintaining a positive company culture. It sets standards of conduct and behavior for employees, ensuring that they align with the company’s values and mission. The manual acts as a reference point for employees to understand the expectations regarding behavior, communication, and professionalism. By providing a clear framework, the manual helps foster a culture of respect, fairness, and accountability.

What is the importance of a policies & procedures manual in ensuring a successful business cycle?

A policies & procedures manual serves as a management tool that ensures a successful business cycle. It provides step-by-step procedures for various processes, such as hiring practices, payment procedures, emergency procedures, and more. By following these procedures outlined in the manual, employees can perform their tasks efficiently and consistently, leading to a quality output and smooth workflow. The manual also acts as a single source of truth, providing reliable information to employees at every stage of the business cycle.

How can a policies & procedures manual simplify training and promote scalability for a company?

A policies & procedures manual simplifies training by providing a structured methodology for onboarding new employees. It serves as a user manual software that offers guidance on various topics, such as organizational culture, dress code, communication policies, and technology usage procedures. New hires can refer to the manual to understand company policies and procedures quickly, saving time and effort. Additionally, as a company grows, the manual allows for scalability by providing a framework for consistent training and aligning employees with established company practices and values.

Tehsin Bhayani

AirMason was born when Tehsin was trying to create a digital culture book, but couldn’t find any solutions in the market that had all the features he needed. In 2016, AirMason officially launched. In five years, AirMason has created thousands of handbooks for more than 1,000 clients around the world.

Mastering Documentation: How to Write a Policy and Procedure

A detailed look at the policy writing template, press esc to close.

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3.4 Delegation

There has been significant national debate over the difference between assignment and delegation over the past few decades. In 2019 the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) published updated joint National Guidelines on Nursing Delegation (NGND). [1] These guidelines apply to all levels of nursing licensure (advanced practice registered nurses [APRN], registered nurses [RN], and licensed practical/vocational nurses [LPN/VN]) when delegating when there is no specific guidance provided by the state’s Nurse Practice Act (NPA). [2] It is important to note that states have different laws and rules/regulations regarding delegation, so it is the responsibility of all licensed nurses to know what is permitted in their jurisdiction.

The NGND defines a delegatee as an RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN, is competent to perform the task, and verbally accepts the responsibility. [3] Delegation is allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed, but the individual has obtained additional training and validated their competence to perform the delegated responsibility. [4]   However, the licensed nurse still maintains accountability for overall client care. Accountability is defined as being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard. Therefore, if a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity themselves. [5]

Delegation is summarized in the NGND as the following [6] :

• A delegatee is allowed to perform a specific nursing activity, skill, or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
• The delegatee has obtained the additional education and training and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility, as well as to the level of the practitioner (e.g., RN, LPN/VN, AP) to whom the activity, skill, or procedure has been delegated. The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, but the delegatee bears the responsibility for completing the delegated activity, skill, or procedure.
• The licensed nurse cannot delegate nursing clinical judgment or any activity that will involve nursing clinical judgment or critical decision-making to AP.
• Nursing responsibilities are delegated by a licensed nurse who has the authority to delegate and the delegated responsibility is within the delegator’s scope of practice.

An example of delegation is medication administration that is delegated by a licensed nurse to AP with additional training in some agencies, according to agency policy. This task is outside the traditional role of AP, but the delegatee has received additional training for this delegated responsibility and has completed competency validation in completing this task accurately.

An example illustrating the difference between assignment and delegation is assisting patients with eating. Feeding patients is typically part of the routine role of AP. However, if a client has recently experienced a stroke (i.e., cerebrovascular accident) or is otherwise experiencing swallowing difficulties (e.g., dysphagia), this task cannot be assigned to AP because it is not considered routine care. Instead, the RN should perform this task themselves or delegate it to an AP who has received additional training on feeding assistance.

The delegation process is multifaceted. See Figure 3.2 [7] for an illustration of the intersecting responsibilities of the employer/nurse leader, licensed nurse, and delegatee with two-way communication that protects the safety of the public. “Delegation begins at the administrative/nurse leader level of the organization and includes determining nursing responsibilities that can be delegated, to whom, and under what circumstances; developing delegation policies and procedures; periodically evaluating delegation processes; and promoting a positive culture/work environment. The licensed nurse is responsible for determining client needs and when to delegate, ensuring availability to the delegatee, evaluating outcomes, and maintaining accountability for delegated responsibility. Finally, the delegatee must accept activities based on their competency level, maintain competence for delegated responsibility, and maintain accountability for delegated activity.” [8]

Five Rights of Delegation

How does the RN determine what tasks can be delegated, when, and to whom? According to the National Council of State Boards of Nursing (NCSBN), RNs should use the five rights of delegation to ensure proper and appropriate delegation: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation [9] :

• Right task: The activity falls within the delegatee’s job description or is included as part of the established policies and procedures of the nursing practice setting. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
• Right circumstance: The health condition of the client must be stable. If the client’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation. [10]
• Right person: The licensed nurse, along with the employer and the delegatee, is responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity. [11]
• Right directions and communication: Each delegation situation should be specific to the client, the nurse, and the delegatee. The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. This communication includes any data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation. The delegatee must understand the terms of the delegation and must agree to accept the delegated activity. The licensed nurse should ensure the delegatee understands they cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse. [12]
• Right supervision and evaluation: The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating client outcomes. The delegatee is responsible for communicating client information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary. The licensed nurse should ensure appropriate documentation of the activity is completed. [13]

Simply stated, the licensed nurse determines the right person is assigned the right tasks for the right clients under the right circumstances. When determining what aspects of care can be delegated, the licensed nurse uses clinical judgment while considering the client’s current clinical condition, as well as the abilities of the health care team member. The RN must also consider if the circumstances are appropriate for delegation. For example, although obtaining routine vitals signs on stable clients may be appropriate to delegate to assistive personnel, obtaining vitals signs on an unstable client is not appropriate to delegate.

After the decision has been made to delegate, the nurse assigning the tasks must communicate appropriately with the delegatee and provide the right directions and supervision. Communication is key to successful delegation. Clear, concise, and closed-loop communication is essential to ensure successful completion of the delegated task in a safe manner. During the final step of delegation, also referred to as supervision , the nurse verifies and evaluates that the task was performed correctly, appropriately, safely, and competently. Read more about supervision in the following subsection on “ Supervision .” See Table 3.4 for additional questions to consider for each “right” of delegation.

Table 3.4 Rights of Delegation [14]

Keep in mind that any nursing intervention that requires specific nursing knowledge, clinical judgment, or use of the nursing process can only be delegated to another RN. Examples of these types of tasks include initial preoperative or admission assessments, client teaching, and creation and evaluation of a nursing care plan. See Figure 3.3 [15] for an algorithm based on the 2019 National Guidelines for Nursing Delegation that can be used when deciding if a nursing task can be delegated. [16]

Responsibilities of the Licensed Nurse

The licensed nurse has several responsibilities as part of the delegation process. According to the NGND, any decision to delegate a nursing responsibility must be based on the needs of the client or population, the stability and predictability of the client’s condition, the documented training and competence of the delegatee, and the ability of the licensed nurse to supervise the delegated responsibility and its outcome with consideration to the available staff mix and client acuity. Additionally, the licensed nurse must consider the state Nurse Practice Act regarding delegation and the employer’s policies and procedures prior to making a final decision to delegate. Licensed nurses must be aware that delegation is at the nurse’s discretion, with consideration of the particular situation. The licensed nurse maintains accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure. If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity. [17]

1. The licensed nurse must determine when and what to delegate based on the practice setting, the client’s needs and condition, the state’s/jurisdiction’s provisions for delegation, and the employer’s policies and procedures regarding delegating a specific responsibility. The licensed nurse must determine the needs of the client and whether those needs are matched by the knowledge, skills, and abilities of the delegatee and can be performed safely by the delegatee. The licensed nurse cannot delegate any activity that requires clinical reasoning, nursing judgment, or critical decision-making. The licensed nurse must ultimately make the final decision whether an activity is appropriate to delegate to the delegatee based on the “Five Rights of Delegation.”

• Rationale: The licensed nurse, who is present at the point of care, is in the best position to assess the needs of the client and what can or cannot be delegated in specific situations. [18]

2. The licensed nurse must communicate with the delegatee who will be assisting in providing client care. This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the client’s condition/stability, any specific information pertaining to a certain client (e.g., no blood draws in the right arm), and any specific information about the client’s condition that should be communicated back to the licensed nurse by the delegatee.

• Rationale: Communication must be a two-way process involving both the licensed nurse delegating the activity and the delegatee being delegated the responsibility. Evidence shows that the better the communication between the nurse and the delegatee, the more optimal the outcome. The licensed nurse must provide information about the client and care requirements. This includes any specific issues related to any delegated responsibilities. These instructions should include any unique client requirements. The licensed nurse must instruct the delegatee to regularly communicate the status of the client. [19]

3. The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it themselves if the client’s condition or other circumstances warrant doing so.

• Rationale: Delegation calls for nursing judgment throughout the process. The final decision to delegate rests in the hands of the licensed nurse as they have overall accountability for the client. [20]

4. The licensed nurse must follow up with the delegatee and the client after the delegated responsibility has been completed.

• Rationale: The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure. [21]

5. The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader. Licensed nurses in the facility need to communicate to the nurse leader responsible for delegation any issues arising related to delegation and any individual whom they identify as not being competent in a specific responsibility or unable to use good judgment and decision-making.

• Rationale: This will allow the nurse leader responsible for delegation to develop a plan to address the situation. [22]

The decision of whether or not to delegate or assign is based on the RN’s judgment concerning the condition of the client, the competence of the nursing team member, and the degree of supervision that will be required of the RN if a task is delegated. [23]

Responsibilities of the Delegatee

Everyone is responsible for the well-being of clients. While the nurse is ultimately accountable for the overall care provided to a client, the delegatee shares the responsibility for the client and is fully responsible for the delegated activity, skill, or procedure. [24] The delegatee has the following responsibilities:

1. The delegatee must accept only the delegated responsibilities that they are appropriately trained and educated to perform and feel comfortable doing given the specific circumstances in the health care setting and client’s condition. The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe they have the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the nursing leadership if they do not feel they have received adequate training to perform the delegated responsibility, do not perform the procedure frequently enough to do it safely, or their knowledge and skills need updating.

• Rationale: The delegatee shares the responsibility to keep clients safe, and this includes only performing activities, skills, or procedures in which they are competent and comfortable doing. [25]

2. The delegatee m ust maintain competency for the delegated responsibility.

• Rationale: Competency is an ongoing process. Even if properly taught, the delegatee may become less competent if they do not frequently perform the procedure. Given that the delegatee shares the responsibility for the client, the delegatee also has a responsibility to maintain competency. [26]

3. The delegatee must communicate with the licensed nurse in charge of the client. This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a client’s condition, and any other information important to the client’s care.

• Rationale: The delegatee is a partner in providing client care. They are interacting with the client/family and caring for the client. This information and two-way communication are important for successful delegation and optimal outcomes for the client. [27]

4. Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy.

• Rationale: The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though they need assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines they need to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse. [28]

Responsibilities of the Employer/Nurse Leader

The employer and nurse leaders also have responsibilities related to safe delegation of client care:

1. The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility. If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.

• Rationale: The nurse leader has the ability to assess the needs of the facility, understand the type of knowledge and skill needed to perform a specific nursing responsibility, and be accountable for maintaining a safe environment for clients. They are also aware of the knowledge, skill level, and limitations of the licensed nurses and AP. Additionally, the nurse leader is positioned to develop appropriate staffing models that take into consideration the need for delegation. Therefore, the decision to delegate begins with a thorough assessment by a nurse leader designated by the institution to oversee the process. [29]

2. The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom, and under what circumstances. The nurse leader must be aware of the state Nurse Practice Act and the laws/rules and regulations that affect the delegation process and ensure all institutional policies are in accordance with the law.

• Rationale: A systematic approach to the delegation process fosters communication and consistency of the process throughout the facility. [30]

3. Policies and procedures for delegation must be developed. The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state Nurse Practice Act. (Institution/employer policies can be more restrictive, but not less restrictive.)

• Rationale: Policies and procedures standardize the appropriate method of care and ensure safe practices. Having a policy and procedure specific to delegation and delegated responsibilities eliminates questions from licensed nurses and AP about what can be delegated and how they should be performed. [31]

4. The employer/nurse leader must communicate information about delegation to the licensed nurses and AP and educate them about what responsibilities can be delegated. This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.

• Rationale: Licensed nurses must be aware of the competence level of staff and expectations for delegation (as described within the policies and procedures) to make informed decisions on whether or not delegation is appropriate for the given situation. Licensed nurses maintain accountability for the client. However, the delegatee has responsibility for the delegated activity, skill, or procedure.

In summary, delegation is the transfer of the nurse’s responsibility for a task while retaining professional accountability for the client’s overall outcome. The decision to delegate is based on the nurse’s judgment, the act of delegation must be clearly defined by the nurse, and the outcomes of delegation are an extension of the nurse’s guidance and supervision. Delegation, when rooted in mutual respect and trust, is a key component to an effective health care team.

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation . https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• “Delegation.png” by Meredith Pomietlo for Chippewa Valley Technical College  is licensed under  CC BY 4.0 ↵
• NCSBN. (n.d.). Delegation. https://www.ncsbn.org/1625.htm ↵
• "Delegation Decision Tree.png" by Meredith Pomietlo for  Chippewa Valley Technical College  is licensed under  CC BY 4.0 ↵

An RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN (where the state’s Nurse Practice Act allows), is competent to perform the task, and verbally accepts the responsibility.

Allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed.

Being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard.

Appropriate monitoring of the delegated activity, evaluation of client outcomes, and follow up with the delegatee at the completion of the activity.

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Key takeaways

Successful project management depends on a team-wide understanding of roles and responsibilities. Using a RACI matrix to assign and define each role is a great way to keep a project on track and positioned for success.

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How Does a RACI Chart Help Project Managers?

Project managers use RACI charts to keep track of team roles and relay those responsibilities to the larger team. The matrix defines clear roles and responsibilities for individual team members across the various phases of the project, breaking each role down into four types of designation: those who are Responsible and Accountable for project deliverables, those who should be Consulted as work begins, and stakeholders who need to be Informed of ongoing progress, roadblocks, and updates. 

Read more: Project Management Phases

RACI Matrix Definitions 

Responsible.

The individual(s) with responsibility for the task or deliverable is typically responsible for developing and completing the project deliverables themselves. The responsible parties are typically hands-on team members who make direct contributions toward the completion of the project. The responsible team is comprised of the project’s “doers”, working hands-on to ensure that each deliverable is completed. 

Some examples of responsible parties are:

• Project Managers
• Business Analysts
• Graphic Designers
• Copywriters

Accountable

Accountable parties ensure accountability to project deadlines, and ultimately, accountability to project completion. This group frequently also falls under the informed category.

Some examples of accountable parties are:

• Product Owners
• Signature Authorities
• Business Owners
• Key Stakeholders

Consulted individuals’ opinions are crucial, and their feedback needs to be considered at every step of the game. These individuals provide guidance that is often a prerequisite to other project tasks, for example, providing legal guidance on a project throughout the process. If you are working on new product development or expansion, this could essentially be the entire organization.

Some examples of consulted parties are:

• Legal Experts
• Information Security and Cybersecurity Experts
• Compliance Consultants

Informed persons are those that need to stay in the loop of communication throughout the project. These individuals do not have to be consulted or be a part of the decision-making, but they should be made aware of all project updates. Typically, this party are business owners or stakeholders that are more interested in viewing the project at a 30,000-foot view.  Keep this group on your cc list for awareness of topics, decisions, and progress – that includes making them part of the initial project kickoff and project demos as optional attendees. This group often also falls under the accountable group.

Some examples of informed parties are:

• Project Committee Members
• External Stakeholders

Read more: DACI vs RACI Model Guide

Why Are RACI Roles Important?

RACI roles provide a sense of organization and clarity for teams that are looking to divide roles and keep team members accountable for their contributions. Considering that 27% of projects go over budget, for reasons like scope creep and lack of defined roles, RACI roles help position a project for success and avoid common pitfalls. 

Moreover, RACI roles help ensure that communication between all roles is ongoing. When you consider that nearly half of all project spending is at risk of being wasted due to a lack of effective team-based communication, it becomes all that more important to prioritize. Ultimately, teams who prioritize communication and well-defined roles are better off, and RACI roles help teams achieve that goal faster – while providing accountability for each team member’s unique contributions to the success of the project. 

Read More: Top 10 Main Causes of Project Failure

How to Create a RACI Matrix 

If you’re looking to implement a RACI matrix as part of your team’s project planning process, take these steps to create a RACI matrix.

Ensure that you have a thorough understanding of the project and its demands before outlining any further steps by communicating with key stakeholders and decision-makers.

Determine the list of key activities and deliverables from the director of program management or other leadership. 

Determine who is needed to be a part of the project or initiative.

Determine the project roles and responsible job titles and persons for each activity and deliverable.

Hold review sessions with key members of the team for alignment, and if you haven’t already, host a kickoff meeting with the entirety of the team and key stakeholders to unveil the matrix, address questions, and more. 

If the project has already started, it’s not too late to implement a RACI matrix.

• Outline the story. Using research from multiple sources, do a, b, c, and d.
• Utilize steps 2 and 3 (shown above). Ensure the right groups are assigned and engaged. 
• Hold a review session. Ensure that the team acknowledges and discusses the plan and the roles assigned.

Read more: 8 Factors That Lead to Successful Projec ts

Examples of a RACI Matrix

As shown above, a RACI matrix helps break down what roles individuals will play as work is carried out and to what extent they will be involved in the project overall. The horizontal axis represents each person on the project team and the vertical axis represents each task.

Each square of the matrix represents an individual, a task, and that individual’s role within the project, either responsible, accountable, consulted, or informed. In this situation, for example, the project manager is accountable for accessing risk, defining performance requirements, creating designs, executing construction, and approving construction work. However, they are only informed about approving construction work and defining functional and aesthetic needs.

Read more: Understanding Different Types of Stakeholders and Their Roles

Our FREE Downloadable RACI Matrix Template

Who creates the raci matrix.

The RACI matrix — sometimes called RACI model, RACI diagram, or simply just RAC — is created by the project manager at the start of the project as a key part of establishing the initial human resources planning for the project. Because miscommunication is a common threat to any project, RACI charts are a great asset to teams dealing with any type of project, from very simple projects to extremely complex ones. 

Common Mistakes When Creating a RACI Matrix

• Failure to plan ahead: Utilizing a RACI matrix should not be your first step in project planning. Having a fully assembled project team and at least a general idea of a task list and project plans is a better place to start before preparing a matrix.
• Working with too large a team: A RACI matrix is likely not the best bet for a large team, as it will make the matrix hard to understand and overly complex.
• Not communicating with the project team: A RACI matrix should help organize tasks and responsibilities that have already been introduced to the project team – no one likes to be blindsided. Be sure to host a kickoff meeting with the team first before creating a RACI matrix.

Frequently Asked Questions

Implementing a RACI matrix takes more than just a few emails and sporadic conversations – it takes consistent communication and planning. You should host a kickoff meeting to introduce the matrix to the team and make a plan to continue meeting at predetermined times throughout the project lifecycle. 

Here are a few more tips to keep in mind as you implement your RACI matrix within the team dynamic:

• Get everyone prepared. Send the document around to the meeting distribution as read-ahead material, requesting feedback if there are any major concerns. 
• Roll out each role for the team . During the meeting, conduct a review of the tasks and responsible parties. Do not rush through this review, but rather ensure enough time in your project kickoff for this important aspect. (Be certain to clarify the definitions of RACI to avoid ambiguity.)
• Consider changes and update accordingly. After the meeting, send out the notes documenting acceptance or updates to the RACI. In addition to sending out the notes, request any corrections within a reasonable yet defined timeframe. Clarify that if no changes are requested, each person is acknowledging their role and committing to the project tasks as outlined.
• Stay in touch. Consider a quick review with the entire team each quarter or every six months for longer projects to ensure it remains up-to-date and not simply another document in the repository but a relied-upon artifact.

As you implement the RACI matrix…

• Encourage teamwork and foster collaboration whenever possible.
• Don’t fear updates – make changes and adjustments as needed (but be sure to communicate those changes clearly to all parties).
• Earlier is better. Roll out your matrix plan to the team BEFORE you plan to implement it for the best results. 
• Have a clear-cut understanding of the project scope and how each role connects to the overall project goal.

For “Responsible” Parties:

• Make sure your project’s definition of Responsible is clear on who holds the “decider” role for the project or project phase’s completion, and what the dimensions of that responsibility will be.
• Ensure that all parties are aware of their role and responsibilities within the matrix.

For “Accountable” Parties: 

• When multiple Accountable team members must exist, use your definitions to make clear which individual is accountable for a given project element, and how that individual needs to interact with other Accountable team members.
• Ensure that there is only one “Accountable” party assigned per task.
• Be sure that the Accountable party has the authority and power to oversee the task as the accountable party.

For Consulted and Informed Parties: 

• Consulted parties are often high-level decision-makers with heavy schedules. Make sure you’re clear on their availability ahead of time.
• Similar to Consulted parties, Informed parties are often less hands-on and have less understanding of day-to-day project operations. As the project goes on, make sure to keep detailed notes to keep the Informed party up-to-date on key information. 
• Understand the ways that these parties like to communicate and create a plan to reach them early – whether that’s over phone calls, emails, video calls, or from within your project management system’s collaboration tools.
• Knowing the difference between who needs to be consulted versus informed can be a challenge if there is ambiguity about project roles. Consider what aspects of the project different team members need to know to do their jobs, and then bake those into your definitions.

RACI Matrix Pros & Cons

• Increased Engagement: RACI helps engage project participants in the project lifecycle. 
• Enhanced Project Planning: Project managers make project planning more organized, efficient, and detailed.
• Identifiable Improvement Opportunities: Areas of improvement are more easily identified.
• Easier Collaboration: Use of a RACI matrix creates a clear path for leadership to sign off on project steps, as project documentation in the RACI model is heavily emphasized.
• Better Communication: Improves overall group communication as a whole.
• Group Accountability: Assists groups, especially larger project teams, stay connected and accountable to their roles and project goals
• Limitations on Role Scope: The RACI model does not provide details on role scope, especially for responsible parties. These gaps in detail also affect other team roles, for example, another gap in a RACI is the determination of who is responsible for verifier and signatory.
• Limits on Task Details and Scope: While a RACI matrix can provide an overview of who is responsible for different tasks, it will not state what needs to be done.
• Not Aligned to the Agile Methodology: Project managers using an agile methodology like scrum may find it redundant since accountability, ownership, and ongoing communication is built into the scrum framework (i.e., product owner, scrum master, and daily standups with the team). Additionally, agile focuses on team-based delivery and accountability, while the RACI framework and alternatives focus on individual responsibility and autonomous accountability.

Read more: Top 10 Causes of Project Failure

Free RACI Matrix Templates

A number of project management software solutions include a native RACI matrix template. Here are just a few we’ve found:

Colorful RACI Chart Template

We love this template from Smartsheet because it’s colorful, thorough, and includes room for every party involved in the project. 

Pastel Colored RACI Matrix Template

This template from the Academy to Innovate HR is a great choice for project managers who want to organize their team roles with an easy-on-the-eyes chart that evolves beyond the simple spreadsheet. 

Simple RACI Chart from Clickup

These RACI templates from Clickup have enough variety to fit any of your project needs, but are simple enough for even beginner PMs to use.

Detailed RACI Matrix Template

This template is a great starter template for anyone looking to explore RACI charts in their project management strategy . As an added bonus – it comes with the RACI definitions already built in!

Excel-Based RACI Chart Template

Are you an Excel or Google Sheets user looking to take advantage of the RACI matrix? An Excel-formatted template from Project Management Docs can be just the solution for you. This template is a great template for users who want a chart that comes in a pre-formatted structure.

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Policies and Procedures in the Workplace: The Ultimate Guide

Developing and enforcing strong policies and procedures improves workplace culture and protects your organization from potential lawsuits.

See How Case IQ Can Help You Improve Work Policies and Procedures

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According to a study by Covestro , 71 per cent of executives say employees’ desire for purpose is “prompting HR to rethink certain work policies such as paid time-off for volunteer or community work, flextime and/or telecommuting.”

Organizations need to develop or improve work policies and procedures that reflect their vision, values and culture as well as the needs of their employees. Once they are in place, enforcing these guidelines is even more important. However, accomplishing these goals can be tougher than it sounds.

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Case management software helps you identify and monitor areas of risk in your organization, including harassment, discrimination, safety and misconduct. Download our free eBook to learn more.

What are Policies and Procedures?

Policies and procedures go hand-in-hand but are not interchangeable.

A  policy  is a set of general guidelines that outline the organization’s plan for tackling an issue. Policies communicate the connection between the organization’s vision and values and its day-to-day operations.

A  procedure  explains a specific action plan for carrying out a policy. Procedures tells employees how to deal with a situation and when.

Using policies and procedures together gives employees a well-rounded view of their workplace. They know the type of culture that the organization is striving for, what behavior is expected of them and how to achieve both of these.

RELATED: Employee Handbook Updates

The Importance of Policies and Procedures

Regardless of your organization’s size, developing formal policies and procedures can make it run much more smoothly and efficiently. They communicate the values and vision of the organization, ensuring employees understand exactly what is expected of them in certain situations.

Because both individual and team responsibilities are clearly documented, there is no need for trial-and-error or micromanaging. Upon reading the workplace policies and procedures, employees should clearly understand how to approach their jobs.

Formal policies and procedures save time and stress when handling HR issues. The absence of written policies results in unnecessary time and effort spent trying to agree on a course of action. With strict guidelines already in place, employees simply have to follow the procedures and managers just have to enforce the policies.

Implementing these documents also improves the way an organization looks from the outside. Formal policies and procedures help to ensure your company complies with relevant regulations. They also demonstrate that organizations are efficient, professional and stable. This can lead to stronger business relationships and a better public reputation.

How to Develop Policies and Procedures in the Workplace

When creating a policy or procedure for your workplace, start by reviewing the mission statement, vision and values. According to the New South Wales Government Industrial Relations , “a workplace policy should:

• set out the aim of the policy
• explain why the policy was developed
• list who the policy applies to
• set out what is acceptable or unacceptable behavior
• set out the consequences of not complying with the policy
• provide a date when the policy was developed or updated”

Once you implement your policies and procedures, the next step is to inform and train employees on them. You can’t expect employees to follow guidelines if they aren’t aware of them. Be sure to schedule regular refresher training sessions, too, to keep employees on track.

Paychex WORX says that “employees may be more likely to embrace rules when they understand their purpose and that they are not meant to be a form of control or punishment.” For this reason, keep a positive attitude during training sessions and leave plenty of time for employee questions.

Company policies and procedures should not be written once and left alone for decades. Reviewing these documents regularly and updating them when necessary is key to their success. In addition to an annual review, consider updating them when you:

• adopt new equipment, software, etc.
• see an increase in accidents or failures on-site
• experience increased customer complaints
• have a feeling of general confusion or increased staff questions regarding day-to-day operations
• see inconsistency in employee job performance
• feel increased stress levels across the office

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Types of Policies and Procedures Every Workplace Needs

Organizations need policies and procedures for a wide range of HR topics. Below are some of the subjects you should consider creating guidelines for.

Polices and Procedures for Attendance

Absenteeism costs wages for the employee who doesn’t show up, wages for a replacement worker, and delays and disruptions to the whole organization. That’s why you need to write (and consistently apply) attendance policies.

These documents can include guidelines on tardiness, vacation time, sick leave, appointments and paid volunteer hours. You can also include the amount of notice required before booking time off. Take your corporate culture into consideration when developing these rules.

Policies and Procedures for Employee Conduct

This is a broad topic and may require multiple, separate policies. Including guidelines on drugs and alcohol use, smoking, performance management and discipline helps employees know what is and is not acceptable behavior at work.

Policies and Procedures for Use of Company Property

The number of ways employees can misuse company property is never-ending. “Renting out the company’s equipment to third parties, intentionally producing scrap product that is actually being sold by the employee, taking vehicles for recreation, hosting their own websites on company servers, even directing other employees to preform tasks that unknowingly benefit the ghost business” are just a few examples of risks your organization could face, according to ASG Investigations .

Employees have to use company property in order to do their jobs. Depending on your industry, this could include electronics, medical equipment, vehicles, tools and uniforms. Include guidelines on how to care for company property, as well as how much (if any) and what types of personal use are permitted using company property.

Policies and Procedures for Harassment and Discrimination

Did you know that the average harassment lawsuit costs the employer $250,000 to defend? With rules in place, you can prevent these incidents and protect both your company and your employees.

Harassment and discrimination affect the entire workplace culture. Keep employees safe and treat them fairly by developing policies and procedures that prohibit behaviors such as:

• sexual harassment
• verbal and physical harassment
• hiring discrimination
• workplace discrimination

Include information on how to report harassment and discrimination and explain that the company will not retaliate for reporting.

Policies and Procedures for Internet and Social Media Use

Make employees aware that any internet use at work is not private. Urge employees to limit personal internet use and ensure everything they do online in the workplace is legal, ethical and appropriate (and explain what these mean). Add guidelines about what is and is not appropriate to post on social media regarding your organization as well.

RELATED: 16 Tips for Managing Social Media in the Workplace to Help You Avoid Scandals

Policies and Procedures for Health and Safety

In 2020, OSHA awarded workers $30.1 million in settlements, nearly double the total from the year before. Without strong health and safety policies that are actually enforced, your employees and your organization are at risk.

Protecting employees’ safety and well-being should be every organization’s top priority. When writing your health and safety policies, include information about how to deal with illness or injury at work, equipment safety guidelines and how to report a health or safety concern. Also include procedures to follow in the event of a fire or natural disaster.

Policies and Procedures for Expenses

If your employees travel or purchase things for work, having an expense reimbursement policy in place is essential. Explain what types of expenses are acceptable for reimbursement (airfare class, transportation, meals, etc.). Include procedures on how to submit a reimbursement claim.

Policies and Procedures for Remote Work

With a desire for more flexibility in location and hours, as well as the COVID-19 pandemic, many companies and employees are choosing to work remotely at least some of the time. If you allow employees to work from home, you need two main policies to ensure the set-up is safe and runs smoothly.

First, a general remote work policy should describe who can work remotely and how often. What hours do remote workers need to be available? What communication standards must they meet? Will you provide necessary work equipment or reimburse employees for their purchases?

In addition, include health and safety procedures for remote work in either your remote work policy or your regular health and safety policy. These should address how you’ll handle potential ergonomic issues, environment-caused injuries and illnesses, mental health, and fire and weather emergencies.

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Why You Need to Enforce Policies and Procedures

Company policies and procedures are helpful for making your workplace run more efficiently, but they are only effective if you enforce them. Enforcement of the guidelines guarantees your organization’s operational procedures and decision-making processes are uniform and consistent across cases.

When you don’t enforce your procedures, you put your organization at risk. If an employee or external person comes forward with an allegation against your company, having formal policies and procedures in place strengthens your case.

RELATED: Employee Policy Manuals: What to Include in Your Annual Review

For example, say someone sues your organization for hiring discrimination, claiming that they were not given a job they interviewed for because they have a disability. Having an anti-discrimination policy in place is a strong piece of evidence in your defense.

Or, say that you refuse to reimburse a first-class plane ticket an employee bought to get to a conference. Pointing out that first-class airfare is not eligible for expense reimbursement and having proof of this in your policy protects your organization from legal actions and reputation damage.

Without formal policies and procedures, your organization may not be reaching its potential. Improve work policies and procedures so that they reflect your workplace’s values to create a better environment for all employees.

FAQ’s

What is an example of a policy and a procedure.

An example of a policy could be an organization’s stance on workplace harassment, outlining what behavior is unacceptable and the consequences for violating the policy. Its corresponding procedure might detail the steps an employee should take to report a harassment incident, including who to contact and how the investigation process will unfold.

How do you organize policies and procedures?

Policies and procedures can be organized by grouping them into categories based on their subject matter (e.g., attendance, employee conduct, company property use, harassment and discrimination, internet and social media use, health and safety, expenses remote work). Each category can then contain individual policies and procedures relevant to that topic, creating an easy-to-read resource for employees to reference as they need.

What is an example of a policy in the workplace?

An example of a policy in the workplace is an attendance policy, which should contain guidelines regarding tardiness, vacation time, sick leave, appointments, and paid volunteer hours, among other related matters.

Jump to a section:

• 1. What are Policies and Procedures?
• 2. The Importance of Policies and Procedures
• 3. How to Develop Policies and Procedures in the Workplace
• 4. Types of Policies and Procedures Every Workplace Needs
• 5. Why You Need to Enforce Policies and Procedures

Related Resources

What to ask in a whistleblower hotline use survey (and why it’s important), how an hr analyst can help your organization reduce risk.

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• Public Health Infrastructure Grant
• Frequently Asked Questions
• Health Department Profiles
• CDC's Public Health Infrastructure Grant (PHIG) is a groundbreaking investment supporting critical public health infrastructure.
• The goal is to support health departments across the United States.
• One hundred and seven health departments and three national public health partners received funding through this 5-year grant (12/1/2022 - 11/30/2027)
• The purpose is to implement activities that strengthen public health outcomes.
• PHIG is a funding model that gives health departments the flexibility to direct funds towards specific organizational and community needs.

In January 2024, CDC awarded $4.35 billion through the Public Health Infrastructure Grant ( OE22-2203: Strengthening U.S. Public Health Infrastructure, Workforce, and Data Systems ) to help U.S. health departments promote and protect health in their communities.

The total award includes $4.01 billion for health departments and $340 million for three national public health partners.

CDC expects to award more than $5 billion over the 5-year grant period. This includes $4.01 billion for health departments and $340 million for three national public health partners.

The purpose is to create a stronger, more resilient public health system that is ready to face future health threats.

Recipient Health Department Profiles‎

Funding recipients.

Funding was awarded to:

• One hundred seven (107) public health departments in all 50 states, Washington D.C., 8 territories/freely associated states, and 48 large localities (cities serving a population of 400,000 or more and counties serving a population of 2,000,000 or more based on the 2020 U.S. Census). Award amounts were based on a funding formula that included population size and community resilience. As of January 2024, a total of $4.01 billion for health departments [$3.685 billion in fiscal year (FY)23 and $325 million in FY24] has been awarded. Recipient-specific information is provided on the Health Department Profiles .
• Three national partners that support the work of the 107 funded health departments. The Association of State and Territorial Health Officials (ASTHO) , National Network of Public Health Institutes (NNPHI) , and Public Health Accreditation Board (PHAB) received a total of $340 million ($155 million in FY23 and $185 million in FY24) . These organizations provide training and technical assistance, evaluate the program, and facilitate coordination and communication across recipients and CDC.

Strategies and outcomes

The three strategies of this grant are Workforce, Foundational Capabilities, and Data Modernization. Recipients are expected to achieve several key outcomes by the end of the 5-year performance period (see image below). Ultimately, this grant will lead to accelerated prevention, preparedness, and response to emerging health threats. Improved outcomes in other public health areas are also anticipated.

All work done as part of this grant is grounded in three key principles:

• Data and evidence drive planning and implementation.
• Partnerships play a critical role in grant program success.
• Resources are directed to support diversity and health equity.

Recipient resources

Technical assistance ‎, phig project officer assignments‎, fiscal year 2023 funding‎, fiscal year 2024 funding‎.

CDC's Public Health Infrastructure Grant (PHIG) is a significant investment in America's public health system, directly supporting infrastructure (i.e., people, services, and systems) improvements within health departments.

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The grades of “CR,” “NC,” “AU” (audit), “I,” “W,” “WB,” and “RP” (report in progress) receive no grade points and the units are not considered in computing grade point average. A plus or minus sign following a grade of “A,” “B,” “C,” or “D” will affect the grade points allowed as indicated in the table. A grade of “A+” cannot exceed 4.0 grade points per California Code of Regulations, Title 5, Division 5, Chapter 1, Subchapter 2, Article 2, 40104.

Undergraduate and post-baccalaureate students must maintain an SJSU Cumulative GPA of 2.0 or better (calculated by dividing grade points (GP) by units graded (UG). See  Disqualification and Probation for Undergraduate and Post-baccalaureate students   .

Auditing a Class - “AU”

An auditor must be officially enrolled in the course. Enrollment as an auditor is subject to permission of the instructor provided there is space available in the course. Auditors are subject to the same fee structure as credit students, and regular class attendance is expected. Once enrolled as an auditor, a student may not change to credit status unless such a change is requested no later than the last day to add classes in that term. A student who is enrolled for credit may not change to audit after the last day to add classes in that term.

Credit/No Credit - “CR/NC”

Credit/no credit (cr/nc) - elective (undergraduates only).

An upper-division (Junior or Senior) student shall have the option of taking a maximum of 12 semester units on the basis of Credit/No Credit for courses under the basic letter grade system, as long as the units are not in the major or minor, or in support of, preparation for or prerequisite to the major or minor, or for General Education. Eligible students may choose this option by turning in the  CR/NC Option Form , by the add deadline. Students may accumulate a maximum of 60 semester units of Credit/No Credit grades toward a baccalaureate degree.

In addition to turning in the CR/NC Option form, you must have officially added the class. For undergraduate courses: Credit = A, A-, B+, B, B-, C+, C, C-; No Credit = D+, D, D-, F, IC, WU.

Credit/No Credit (CR/NC) - Mandatory 

“CR/NC” grades are mandatory for thesis and remedial course work. It is also normally used in projects, field work, internships, individual studies, or directed reading. As recommended by departments and approved by the college dean, credit/no credit grades may be used in activity and laboratory courses, workshops, and selected seminars (colloquia). Students may accumulate a maximum of 60 semester units of Credit/No Credit grades toward a baccalaureate degree (excluding any remedial coursework). A maximum of 30 percent of the units required in a graduate degree can be credit/no credit (e.g., 10 units in a 30-unit program). In accordance with University Policy F18-5 :

For undergraduate courses: Credit = A, A-, B+, B, B-, C+, C, C-; No Credit = D+, D, D-, F, IC, WU. For graduate courses: Credit = A, A-, B+, B, B-; No Credit = C+, C, C-, D+, D, D-, F, IC, WU

Incomplete - “I/IC”

The symbol “I” (Incomplete Authorized) indicates that a portion of required coursework has not been completed and evaluated in the prescribed time period due to unforeseen, but fully justified, reasons and that there is still a possibility of earning credit. The instructor needs to create an incomplete grade agreement for the student when an “I” grade is assigned.

The student cannot re-enroll in the course until the course is completed or lapsed to “IC” (Incomplete Charged) which calculates as an F for GPA or an “NC” for non-traditionally graded courses. It is the student’s responsibility to bring pertinent information to the attention of the instructor (regarding the unforeseen reason(s) for requesting an Incomplete) and to determine from the instructor the remaining course requirements that must be satisfied to remove the Incomplete.

In addition, the student must accept the incomplete agreement in a timely manner. See  the Incomplete Grade Agreement guide [pdf]  on how to review and accept the incomplete agreement. A final grade is assigned when the work agreed upon has been completed and evaluated. Clearing an incomplete grade does not permit retaking previously completed portions of the course, nor does it permit the assignment of additional graded work (e.g., extra credit) that was not available to other students in the class.

An “I” must be made up by the specified deadline in the agreement or within one calendar year following the end of the term in which it was assigned, whichever comes first. If students need more time to finish all required coursework beyond the specified Deadline for Completion in the agreement, they need to contact the instructor to request an extension . The maximum time for completion is two years from the semester in which the Incomplete grade was assigned; requests to extend the deadline beyond two years will be denied. This limitation prevails whether or not the student maintains continuous enrollment.

Failure to complete the assigned work will result in an “I” being converted to an “IC” symbol, or an “NC” for non-traditionally graded courses, unless the faculty member assigns a “grade without further work” at the time the Incomplete is assigned, which would replace the “I” in the student’s record after the deadline specified in the Incomplete Agreement.

Report Delayed - “RD”

The “RD” symbol may be used where a delay in the reporting of a grade is due to circumstances beyond the control of the student. The symbol may be assigned by the registrar only and, if assigned, shall be replaced by a substantive grading symbol as soon as possible.

Report in Progress - “RP”

The “RP” symbol is used in connection with courses that typically extend beyond one academic term. It indicates that work is in progress, but that assignment of a final grade must await the completion of additional work. Work is to be completed within one year except for graduate degree projects and theses (supervised courses, e.g., 298 & 299 courses), which have a two-year time limit. Failure to complete the assigned work for an “RP” grade will result in an automatic grade change to an “NC” grade unless a request for an extension has been made and approved.

A final grade will be assigned to all segments of the course based on overall quality. Any extension of this time period must receive prior authorization from the instructor and department chair or school director.

Note: RP grades earned through the Early Start Program between Summer 2012 and Summer 2018 mean that the Early Start requirement was satisfied. but remediation was not completed. These RP grades do not need to be replaced and may appear on a student’s final transcript.

Withdrawal - “W”

The symbol “W” on the official transcript indicates that the student was permitted to withdraw from the course after the drop deadline for the term with the approval of the appropriate campus administrator. It carries no connotation of quality of student performance and is not used in calculating grade point average or progress points. However, there are limits on the number of allowable units of “W” on the official transcript. Undergraduate students may withdraw from no more than 18 units. Post-baccalaureate students may withdraw from no more than 12 units. Graduate students may withdraw from no more than 9 units. Exceptions to these unit limits are granted when the cause of withdrawal is due to circumstances clearly beyond the student’s control, and the assignment of an Incomplete is not practicable. Such exceptions are designated “WB” for internal processing of drops and withdrawals, and will revert to “W” on the transcript (University Policy S09-7 ). The grading symbols “WA” (withdrawals granted only during the first 80% of the term for serious and compelling reasons) and “WB” (withdrawals granted anytime during the term, or retroactively after the term, for serious and compelling reasons due to circumstances clearly beyond the student’s control) do not appear on the transcript. Instead, “WA” and “WB” grades both show as “W” grades on the transcript.

Undergraduates may download the appropriate petition ( course drop or withdrawal from all courses forms ). Graduate Students may download the Course Drop/Semester Withdrawal petition .

Withdrawal Unauthorized - “WU”

The symbol “WU” indicates that an enrolled student did not officially withdraw from the course and also failed to complete course requirements. It is used when, in the opinion of the instructor, completed assignments, course activities, or both were insufficient to make a normal evaluation of academic performance possible. For purposes of grade point average and progress point computation this symbol is equivalent to an “F.”

Grading System for Graduate Work

Traditional letter grades are used for all courses taken by graduate students except for field work, thesis, project, individual study, and internship courses, which are usually graded Credit/No Credit or Credit/No Credit/Report in Progress. Incomplete grades are not permitted for thesis or project courses, and Credit may not be given for a thesis or project course before completion of the coursework. Graduate students do not have the option of choosing between the traditional or non-traditional grading system. A grade of Credit in a graduate-level course indicates performance by the student equal to a letter grade of “B-” or above.

The cumulative GPA for the master’s degree (3.0 minimum) includes all letter-graded work in 100-level or 200-level courses completed within the preceding seven years and for which the student received graduate credit, excluding transfer courses taken at another institution and those taken as an undergraduate at SJSU. Both the cumulative GPA and GPA of all of the course grades on the student’s candidacy form, with the exception of non-Open University transfer courses, must be at least at the 3.0 level. Both the cumulative GPA and the GPA of all courses on the candidacy form must be a minimum of 3.0.

The cumulative GPA of the graduate student is computed by dividing the total number of grade points earned by the total number of graded units attempted at SJSU, excluding Open University courses that are not counted as degree requirements, after enrollment in the graduate school.

Timely Feedback on Class Assignments

In accordance with Students’ Rights to Timely Feedback on Class Assignments, University Policy F13-1 , every student has the right to know, within a reasonable time, his or her academic test scores, to review his or her papers and examinations, and to be provided with an explanation of the determination of his or her course grade.

With changing pedagogical perspectives and increasing use of technology, instructors give a much wider range of assignment types - presentations, online discussion, group projects, etc. - and students should be granted the same expectation for feedback on all assignments within a reasonable period as with papers, tests, and examinations.

Unauthorized Repeats

Students are not permitted to repeat courses in which they originally received a “C” or better, regardless of where they took the course originally. However, if this happens, units and grade points for the repeated courses cannot be counted for graduation credit. While the units and grade points may appear on the transcript and the grade may be calculated into the GPA, such units and grade points for repeated courses will be subtracted when the student applies for graduation or when discovered and brought to the attention of the  Registrar’s Office .

Failure to complete by the deadline, the instructor entered into the agreement, the “I” grade will convert to the grade indicated in the “Grade Without Further Work” section of the agreement. If no grade is indicated, the “I” grade will lapse to an “IC”, which is a failing grade or an “NC” for non-traditionally graded courses.

APS Fellowship Executive and Selection Committee Guidelines

Responsibilities of the unit executive committee and selection committee when nominating and choosing fellows, unit executive committee responsibilities.

Each unit executive committee is responsible for canvassing for nominations, promoting fellowship in the unit, and forming the selection committee.

Canvassing and promotion

At the end of the calendar year, APS staff will distribute a report of the carryover nominations that are still active and eligible for each unit’s honors. Executive committee members should review the existing nomination pool, canvass for a diverse pool of nominees, and send promotional messages via the unit’s communication channels.

Unit officers can request a current list of unit members who are eligible for election to Fellowship by submitting a Unit Statistics Request through the APS Unit Service Desk .

If officers would like to submit a nomination themselves, they may reference the conflict of interest definition and examples to prevent conflicts of interest.

Forming Selection Committees

Selection Committees are formed by the related APS unit. The committee composition varies by unit and may be defined in the unit’s bylaws. At least three reviewers must review each individual nomination. Selection Committees should be sized with this in mind. Committees may have pre-appointed standby members or substitutes, in case they are needed for some nominations. A convening chair, if non-conflicted, could fill this role.

In January, staff will ask each unit’s chair and secretary/treasurer to provide the selection committee at least one month before the fellowship deadline for their unit. If committee selections are dependent on elections and newly filled positions, continuing committee members should be confirmed as soon as possible.

Guidelines for promoting equity

The APS Committees on the Status of Women in Physics and on Minorities have crafted guidelines to improve the effectiveness of award, prize and fellowship committees in finding the most qualified person from a diverse, representative pool of candidates.

Selection Committee responsibilities

Selection Committees are responsible for reviewing nominations and recommending fellows .

The chair’s role

The Selection Committee chair is responsible for ensuring the review and selection process is completed on time and in within the Society’s policies and procedures . The chair facilitates and documents the review and selection process but, if possible, should not score or vote on nominees unless needed as a tiebreaker. The chair may take part in discussion of the nominees but should be mindful of their primary role of facilitator.

Scheduling Selection Committee calls

APS recommends the Selection Committee has at least one conference call to discuss nominees and scoring. APS staff can set up Zoom meetings and provide connection information for the committee’s use. Please request this in advance by emailing the APS Honors team.

If needed, APS staff can host an optional training session for selection committee members to review how to navigate the APS nominations system and answer any questions regarding procedures.

The chair of the Selection Committee will complete the chair report by providing conflict of interest disclosure and the committee’s selections. Some unit bylaws require that the chair report first be shared with the unit executive committee before submission to APS. Once received by APS, staff will submit the reports to the APS Council of Representatives for review and approval.

Selection timeline

APS suggests the following timeline for selections:

• Mid-January: The unit executive committee reviews carryover nominees (if applicable) and begins canvassing and promotion.
• One month before the fellowship deadline: The unit executive committee forms the selection committee and reports the committee roster to APS Honors staff.
• April–June: After the unit fellowship deadline, the selection committee begins its review of nominations.
• April–July: Selection committees complete their deliberations and select fellow(s).
• August 1: The selection committee chair completes and submits the chair report.
• August–September: Fellowship selections are reviewed by the APS Committee on Fellowship and the APS Council Steering Committee.
• October: APS announces fellowship recipients.

Suggested scoring procedure

The optional suggested scoring procedure is intended to calibrate and focus the discussion of nominees, not replace or automate it. This is the process successfully used each year by the APS Medal and Prize Committee and the Apker Award Selection Committee. It is not mandatory if the unit already has a system in place that works well.

After the nomination deadline passes, committee members will be prompted to review nominations in the APS nominations system.

Instructions for scoring in the nominations system

• Log in to the APS nomination system with your myAPS account credentials.
• Select "My Reviewing Assignments."
• Review and rate each nomination from one (least recommended) to five (most recommended).

After the scoring deadline, the chair will review the committee’s scores and facilitate a discussion of the candidates.

The chair may choose to assign each committee member as primary reviewer of a subset of nominations. The primary reviewer should be prepared to briefly summarize the nomination on the committee selection call before discussion. Primary reviewer assignments may be based loosely on area of physics, but not necessarily.

If a clear consensus is not reached on the selection call after discussion of the scoring, voice voting or ranking candidates on the call may help the committee reach a decision.

Conflicts of interest

Conflicts of interest arise between reviewer and nominee in situations where there are close personal or professional relationships, lines of authority, or fiscal responsibility. Some examples include:

• Residing at the same institution, division, or department within the past four years
• Collaborations (co-authors, post-docs, etc.) published within the past four years
• Financial via direct chain of command and/or participation in tenure, promotion, salary, or forms of support by either party
• Member of the same center or sharing any funding contract
• Relationship due to immediate blood relation, current, or prior marriage or civil union
• Current or prior students, advisees, and advisors
• Nominator or participant in the nomination package

Selection Committee members are responsible for disclosing all potential conflicts of interest prior to review and assessment of nominations. The primary conflicts of concern are those between selection committee members and nominees and their institutions. Conflicts between selection committee members and nominators or supporters and their institutions are secondary but should be disclosed so all committee members are aware, and they can be managed by the selection committee. Selection committees are responsible for monitoring, handling, and reporting resolution for conflicts of interest.

Immediately after nominations are available for review, committee members should review the list of nominees and their institutions/departments and disclose to the entire committee any conflicts of interest as described above or other potential conflicts as the list of examples is not exhaustive. The committee should unanimously agree on a response based on the level of the conflict. Recusal from scoring and discussion of the person with whom a committee member has a conflict is likely appropriate for most cases. In more serious cases, a new committee member may need to be identified. In some cases, disclosure to the committee may be considered sufficient. The chair is responsible for documenting the details of each conflict and the committee’s unanimous response in the chair report. If the committee cannot agree unanimously, the conflicted committee member(s) should be recused from scoring and discussing the affected nomination(s).

Given the large size of many institutions where physicists work and the number and variety of their departments/divisions, shared institutional affiliation is less of a concern in these cases than shared department/division affiliation. Similarly, co-authorship of a multi-hundred-author paper from a major collaboration should be addressed pragmatically, based on the closeness of collaboration between the specific committee member and specific nominee.

Confidentiality and information security

Individuals serving on a selection committee must not disclose information about the committee’s business to individuals outside of the selection process. Selection committee business includes the committee’s deliberations, the number of nominations reviewed, conflicts of interest, and other sensitive information. The recommended recipients are not official until approved by the APS Council of Representatives and the recipient has completed a professional conduct disclosure.

Questions and more information

If you have any questions about the review process, please contact the APS Honors team .

Ethics guidelines

Nominees for and holders of APS Honors (prizes, awards, and Fellowship) and official leadership positions are expected to meet standards of professional conduct and integrity as described in the APS Ethics Guidelines . Violations of these standards may disqualify people from consideration or lead to revocation of honors or removal from office.

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Student Life Policies and Procedures

Registration of student organizations.

The contents of this website and the related student organization pages are currently under review. If you have questions regarding a policy or procedure outlined below, please contact Leadership, Service, and Civic Engagement at [email protected] .

A student organization is a voluntary special interest group organized for educational, social, recreational, and service purposes and comprised of its members. Student organizations are separate legal entities from the University of Iowa and legally are not treated the same as University departments or units. Student organizations can exist whether or not the University endorses them pursuant to this policy. Unless otherwise denoted hereafter, the use of the term “student organization” shall include sports clubs registered by Recreational Services.

Student organizations are an important link in the co-curricular activities of the University of Iowa. They play an important role in developing student leadership and providing a quality campus environment. As such, the University encourages the formation of student organizations around the areas of interests of its students, within the limits necessary to accommodate academic needs and ensure public safety.

I. Registration of Student Organizations

The University of Iowa, through the Vice President for Student Life (hereinafter, "vice president"), has delegated the responsibilities and obligations of registering student organizations to the Student Organization Review Committee (i.e., on behalf Leadership & Engagement and Recreational Services) (SORC) and to deans of academic colleges. The SORC is a team of students and staff that determines the approval or denial of the application for registration. Registration of a student organization by the University does not constitute an endorsement of its program or its purposes, but is merely a charter to exist.

Organizations must abide by all local, state, and federal laws. An organization’s goals, objectives, and activities must not deviate from established University policies and procedures. Because participation in student organizations may enhance a student’s educational experience and the University deems this important to our students’ success, registered organizations are entitled to certain privileges and benefits.

The University shall not deny benefits or privileges available to student organizations based on the viewpoint of a student organization or the expression of the viewpoint by the student organization or its members, as protected by the First Amendment to the Constitution of the United States. In addition, the University shall not deny any benefit or privilege to a student organization based on the student organization's requirement that the leaders of the student organization agree to and support its beliefs, as those beliefs are interpreted and applied by the student organization, and to further its mission.

• Registration as a University organization;
• Establishment of an account in the Student Organization Business Office (SOBO), or Recreational Services and appropriate purchasing privileges in accordance with University policies;
• Eligibility to apply for funds from mandatory Student Activity fees (i.e., for student organizations) or Recreational Services fees (i.e., for sports clubs);
• Inclusion in appropriate University publications;
• Utilization of the University of Iowa student organization platform (funded by USG & GPSG)
• Utilization of the University’s trademarks in accordance with the UI Trademark Licensing Department’s program and policies ;
• Eligibility for use of campus meeting facilities and outdoor spaces;
• Eligibility, but not the right, to utilize UI Fleet Services vehicles in accordance with state and University policies, procedures, guidelines, and insurance requirements;
• Eligibility, but not the right, to utilize University staff and programming resources;
• Eligibility, but not the right, to utilize Information Technology Services Mass Mail twice each semester;
• Eligibility to apply for awards and honors presented to University registered organizations and members; and
• Eligibility to apply for Student Organization Office Suite (SOOS) or Student Activity Center (SAC) office space and/or storage space.
• In order to exercise the privileges accorded to registered student organizations, students interested in starting a new registered student organization must first write a constitution for the potential student organization and hold a Pre-registration meeting with the appropriate Leadership & Engagement staff, BEFORE filing the New Organization Registration Form online through the University of Iowa student organization platform. This form includes organizational information and the organization’s Constitution and Bylaws. Upon receiving this information, the Leadership & Engagement staff will review it and submit it to the Student Organization Review Committee (SORC) for consideration. If approved for registration, the SORC will assign the appropriate registration tier (see below).
• Any group or organization which consists of and maintains at least 80 percent University students, whose purposes are consistent with the educational objectives of the University, and do not violate local, state or federal law, is eligible for registration by the University. To start a new registered student organization, the organization must consist of and maintain at least five (5) individuals as members, of which four (4) must be currently enrolled UI students.
• Membership and Leadership. It is the policy of the University that all registered student organizations be able to exercise free choice of members on the basis of their merits as individuals without restriction in accordance with the University Policy on Human Rights. The University acknowledges the interests of students to organize and associate with like-minded students, therefore any individual who subscribes to the goals and beliefs of a student organization may participate in and become a member of the organization.

Membership and participation in the organization must be open to all students without regard to race, creed, color, religion, national origin, age, sex (unless the organization is exempt under Title IX), pregnancy, disability, genetic information, status as a U.S. veteran, service in the U.S. military, sexual orientation, gender identity, associational preferences, or any other classification that deprives the person of consideration as an individual. The organization will guarantee that equal opportunity and equal access to membership, programming, facilities, and benefits shall be open to all persons.

The University shall not deny any benefit or privilege to a student organization based on the student organization’s requirement that the leaders of the student organization agree to and support its beliefs, as those beliefs are interpreted and applied by the student organization, and to further its mission.

The University will not investigate complaints related to student organization leadership selection processes or final leadership selection by organizations that select their leaders on the basis of a commitment to a set of beliefs or affirmations. These selection processes are defined and enforced by individual student organizations and the university shall respect the organization’s decision-making process.

Membership in a student organization must be composed primarily of UI students (minimum 80% student membership) and be controlled and directed by UI students. Members are individuals who self-select to join an organization; “membership” is different from the audience a student organization targets, serves, or represents. The “audience” is not automatically considered a part of the organization’s membership. Only UI student members shall have voting rights in a student organization. Membership is not open to persons under the age of 18 who are not enrolled UI students. Non-university community members who are at least 18 years of age may participate in the activities of student organizations but may not be voting members. If the student organization desires to allow persons under the age of 18 who are not UI students to participate in the activities of the student organization, the student organization must follow the requirements contained in the Youth Programs Policy Manual for RSOs, including that the youth participant must have permission to participate from a parent or guardian.

As some University services and benefits require knowledge of a student’s membership in the student organization requesting the service or benefit, all organizations are encouraged to have a full membership roster on file with Leadership & Engagement via the University of Iowa student organization platform. For example, if a member of a student organization wants to request approval to drive or ride in a university vehicle for an organization event or activity, that member must be listed on the organization’s full membership roster located on the University of Iowa student organization platform.

The student organization must be nonprofit in nature; student organizations affiliated with for-profit businesses are not eligible for registration. Student Representatives and student organization members must not profit or benefit financially from student organization membership.

• Primary and Secondary Student Representatives. Student Representatives are individuals who are authorized by the organization to speak for or represent the organization in its relations with the University and who are authorized to receive for the organization official notices, directives, or information from the University. Every student organization or potential student organization registered with Leadership & Engagement/Recreational Services/academic deans via the University of Iowa student organization platform must include the names of two student representatives in its Organization Profile. Both Representatives must be currently enrolled UI students, and in academic and non-academic good-standing. One name will be designated as the Primary Representative and the other as the Secondary Representative. It is the responsibility of each student organization to update the Organization Profile with the current names of Student Representatives. A student organization no longer under the direction of currently enrolled students may lose its registration.
• Access to University Resources. Registered student organizations are guaranteed an equal opportunity to apply for funds from mandatory Student Activity fees (i.e., for student organizations) or Recreational Services fees (i.e., for sports clubs) or for any other benefit conferred by the Undergraduate Student Government (USG) or Graduate and Professional Student Government (GPSG) or their constituent bodies, without differentiation for reasons that violate the University Policy on Human Rights or inhibit the group’s exercise of First Amendment rights of free expression and association. Nothing in this section shall be construed to create or guarantee any expectation of the receipt of funding or other benefits from USG and/or GPSG and/or Recreational Services by any student organization or to prohibit the individual consideration of the program merits of funding or other proposals submitted by such student organizations.
• To start an organization one must follow the step-by-step process listed on the “ Starting an Organization ” website. Registration of student organizations that are residential living units (i.e., residence hall organizations, fraternities, and sororities) is granted by their respective student governance organization (i.e., Associated Residence Halls [ARH], Interfraternity Council [IFC], Multicultural Greek Council [MGC], National Pan-Hellenic Council [NPHC], and Panhellenic Council [PHC]) with the concurrence of the vice president. The Student Organization Review Committee (SORC) shall review all student organization registration applications. Upon its evaluation, the Committee will register the student organization and forward the organization’s application to the appropriate student governance organization or college/department/unit for confirmation; 2) register the organization subject to specific conditions on activities the organization is permitted to sponsor; or 3) reject the application. If an application is rejected the organization may appeal the decision of the SORC within 30 calendar days upon the receipt of their denial of registration letter. Appeals must be submitted in writing to either the Director of Leadership & Engagement (i.e, for student organizations) or the Director of Recreational Services (i.e., for sport clubs). If an organization appeals and is not satisfied with the decision rendered by the Director of Leadership & Engagement or the Director of Recreational Services they may then submit a final appeal in writing to the Dean of Students. There is no further appeal after the Dean of Students.
• Constitution and Bylaws. In order to complete the registration process, all student organizations must have an approved constitution and bylaws. Sponsored and affiliated student organizations (see Section 8, Registration Tiers) must also provide a copy of the charter, constitution, and/or bylaws of any organization external to the University with which such organization may be affiliated. Student organizations are required to include mandatory clauses within their organization constitutions.
• Registration of Inter/National Chartered Organizations. In addition to observing all University rules, an organization that is chartered by an inter/national organization, such as a Greek-letter social fraternity or sorority, must maintain its affiliation with the inter/national organization in order to retain its University registration. University registration will cease when the inter/national organization no longer recognizes or sponsors the student organization as an active organization. In this situation, the organization is no longer eligible to affiliate with their respective student governance organization, to participate in activities sponsored by the governance organization or its member organizations, or to access the privileges granted to registered student organizations. Once the inter/national organization has officially returned the student organization to affiliation status, the student organization representatives may apply to the University and the respective student governance organization for registration, although re-registration is not guaranteed. When the University removes registration of a student organization for violating University rules but the organization remains affiliated with the inter/national organization, the student organization will not regain their University registration by virtue of their relationship with the inter/national organization.
• Manage their housing unit;
• Enforce internal organization rules;
• Ensure that relevant national, state, and local laws and regulations are observed;
• Provide safe and healthful lodging and cooperate with city or state agencies responsible for enforcing applicable health and safety laws; and
• Observe relevant University policies in their housing facilities, including the Anti-Hazing Policy and the Sexual Misconduct Policy.
• Housing Organizations are eligible for the same privileges granted to registered student organizations which do not provide housing.
• The responsibility for the regulation and governance of professional fraternities that maintain chapter structures shall be with the Dean of the respective college, including professional fraternities registered by the College of Medicine, the College of Dentistry, College of Liberal Arts and Sciences, and the Graduate College.
• The possession or consumption of alcohol is prohibited in registered undergraduate residence group housing except where explicitly authorized in writing by the vice president.
• Registered student organizations are governed by the Undergraduate Student Government (USG), Graduate and Professional Student Government (GPSG), or Associated Residence Halls (ARH).
• Undergraduate social fraternities are governed by the University of Iowa Interfraternity Council, Panhellenic Council, National Pan-Hellenic Council, or the Multicultural Greek Council, which may establish, consistent with the University Policy on Human Rights, additional rules and regulations for recognition of new fraternities, membership selection standards, and standards of conduct.
• In order to determine whether a student organization is in compliance with a student governance organization regulation or policy, University officials may from time to time review the organization’s record. Information gathered as part of the review may include, but is not limited to, the following: aggregate grade point averages, membership figures, financial reports, internal rules and policies, insurance coverage schedules, educational programs for members, safety and security precautions, compliance with relevant municipal ordinances and state laws, and complaints to the Iowa City police.

II. Registration Tiers

Each student organization granted registration with the University of Iowa is classified as general, affiliated, or sponsored. The registration tier is determined by assessing the student organization's relationship to the University, the purpose and scope of its activities, the University population served, and the perceived potential risk to participants and the University.

The relationship of student organizations to the University is determined by evaluating the student organization’s mission, goals, and activities as they relate to the mission, vision, goals and culture identified by the University in its Strategic Plan.

The privileges and responsibilities associated with each type of registered student organization are outlined below.

1. General Student Organizations: The privileges of becoming a registered student organization at the University are not extended without careful consideration. General student organizations are those that are consistent with the mission and culture of the University and engage primarily in activities that benefit their membership. These organizations are primarily interest groups capable of functioning with minimal support. The University registers but does not support or endorse the purposes of these general organizations and may not accept responsibility or liability for the activities undertaken by the student organization.

• Student Activity Center (SAC) storage space; and
• Reservable space for University-wide annual events at the Iowa Memorial Union, other University facilities, and outdoor venues through the IMU Event Services process and other University scheduling processes.

2. Affiliated Student Organizations: Affiliated student organizations are those that serve a specific University interest and may provide support to University programs and initiatives. They contribute to the mission, vision, goals, and culture of the University by routinely presenting events for their members, the campus, or their related department’s or unit’s members and invited guests. A University department or unit must provide oversight and direct responsibility for the organization and its activities. Affiliated student organizations also may be directly associated with an academic course and its requirements.

In addition to the University resources available to all registered student organizations, affiliated student organizations shall comply with any rules, procedures, and expectations established by the responsible University department or unit.

Because of their broad impact, affiliated student organizations may receive second priority consideration for:

• Student Organization Office Suite (SOOS) or Student Activity Center (SAC) office or storage space; and
• Reservable space for University-wide annual events at the Iowa Memorial Union, other University facilities, and outdoor venues through the IMU event services process and other University scheduling processes.

Affiliated student organizations will need to follow appropriate criteria and guidelines from each University department or unit to receive these services and benefits.

3. Sponsored Student Organizations: Sponsored student organizations are those considered critical to the mission and culture of the University and work in partnership with a University department or unit. These organizations are linked to the University because of their role representing the University or in presenting events of broad appeal that are considered an integral part of the institution and its activities. Sponsored student organizations routinely present events for the campus and broader community, and typically work in a collaborative relationship with a University department or unit. The student organization's purpose and effect are to serve a broad segment of the campus community, not just its membership.

Once registered, the events and activities presented by the student organization should accurately and positively reflect the mission, vision, goals and culture of the University, as well as the rules and standards of the institution and its activities. The registration process requires action by both student leaders and University officials. As such, this process creates a mutually beneficial relationship between sponsored student organizations and the University.

In addition to the University resources available to all registered student organizations, sponsored student organizations shall have:

• A full-time professional staff or faculty member whose job description designates them as the primary adviser to the sponsored student organization in accordance with student organization registration requirements. These advisers are considered experts within the respective student organization's area of interest;
• A University department or unit that provides oversight and direct responsibility for the student organization and its activities; and
• Routinely presented events of broad appeal for the campus and community. Student organization operations and event planning are complex, and the majority of the events/programs are University-wide. Sponsored student organizations routinely present events for the campus and broader community, and are expected to work closely with the appropriate University department or unit in the planning of these events.

Because of high complexity, sponsored student organizations may receive first priority consideration for:

Sponsored student organizations must follow appropriate criteria and guidelines from each respective University department or unit to receive these services and benefits.

III. Tier Appeals

An appeals process exists for those organizations desiring a registration tier different than that into which they were initially placed. Based on additional information, an organization's registration tier or may be modified also by the Student Organization Review Committee (SORC).

• Appeals – Recognition Tier Decision. A student organization has the right to appeal a tier designation decision of the SORC or the determination by Leadership & Engagement to change or modify a student organization's registration tier. An appeal provides a limited review of the original decision. It is not an opportunity to present the evidence again or to re-evaluate credibility. If an error has been made, in most cases the matter will be returned to the SORC so that the error may be corrected.

One of the following two conditions must be used as a basis for appeal:

• Discovery of new information that was not available at the time of the decision; and/or
• The appropriate processes for registering student organizations were not followed.

The Director of Leadership & Engagement or Recreational Services will act as the appeal administrator. The Associate Director of Leadership, Service, and Civic Engagement or Recreational Services will act as the appeal administrator if the Director is unable to serve due to conflict of interest or absence.

Written documentation stating the grounds for appeal must be filed with the appeal administrator within ten (10) business days of receipt of the original SORC decision.

The appeal administrator will decide one of the following:

• Uphold the original decision;
• Remand the case back to the SORC for reconsideration consistent with the findings of the appeal administrator;
• Remand for a new registration process review of the student organization; or
• Modify the registration tier assigned by the SORC.

The appeal administrator will provide a written decision to the SORC Chair within ten (10) business days of the appeal review. An appeal may be taken within ten (10) business days to the Dean of Students.

IV. Registration Renewal

• Each student organization is required to complete the re-registration process through University of Iowa student organization platform on an annual basis. There are two re-registration windows held each year. An organization’s re-registration window is assigned based on when the organization selects new leadership. Organizations who select new leaders in the fall semester are eligible for re-registration beginning November 1 closing December 31. Organizations who select new leaders in the spring semester are elibgible for re-registration beginning April 1 and closing May 31. (dates are subject to adjustment based on annual calendar changes). Re-registration is required even if there are no changes from the previous semester in primary and/or secondary representative and contact information. A student organization that does not complete the re-registration process will be moved to a temporary inactive status for one semester and will be eligible to re-register in the next open re-registration period. Registered student organizations must provide complete and accurate information as requested in the profile. If additional information is needed, student organization representatives must provide information upon request to Leadership & Engagement or Recreational Services. For those student organizations that are registered by an academic college as well as by a student government, student leaders are advised to check with the college/department/unit regarding registration deadlines. More information regarding student organization re-registration may be found on the Leadership and Engagement re-registration website .
• Periodically, the Student Organization Review Committee reviews the status of student organizations to ensure the safety and welfare of students who participate in activities sponsored by the organization. Depending upon the results of its evaluation, the Committee will 1) register the student organization; 2) register the student organization subject to specific conditions on activities the organization is permitted to sponsor; or 3) recommend to the Director of Leadership & Engagement or Director of Recreational Services that registration be denied.

V. Organizational Registration Changes

• During the year, registered student organizations must report to Leadership & Engagement or Recreational Services any amendments to or changes in its student organization name, constitution, by-laws, student representatives, and/or advisers within two weeks of the changes becoming effective. Registered student organizations also must submit any additional information requested from time to time by their respective registering body.

VI. Advisers

• Student organization advisers are strongly encouraged for all registered student organizations. Advisers shall be faculty members whenever possible in order to promote student-faculty interaction beyond the classroom. Professional & Scientific staff with advising experience and/or relevant expertise also may serve as student organization advisers. Merit staff, with advising experience and/or relevant expertise also may serve as student organization advisers upon approval from the Leadership & Engagement, Recreational Services, or academic dean. A non-University affiliated individual may serve as an adviser to a student organization only if they serve as a liaison to a local/regional/national organization with which the registered student organization has an official affiliation.
• Student organization advisers must be employed at the University on at least a .5 FTE basis. The Division of Student Life shall have the right not to approve advisers of student organizations who are on disciplinary status as determined by the appropriate University department or unit.
• All student organization advisers are strongly encouraged to participate in the adviser training programs sponsored by Leadership & Engagement. Leadership & Engagement and Recreational Services will provide specific information to student organizations about these requirements.
• Graduate assistants, with at least 50% appointments, may serve as additional advisers in conjunction with student organization advisers who meet the requirements stated above; however, they will not have signatory authority (e.g., financial transactions, contracts, vouchers).

VII. Space Allocation for Registered Student Organizations

• Limited office or storage space is available to registered student organizations in the Student Organization Office Suite (SOOS) or Student Activity Center (SAC) in the Iowa Memorial Union. Student organizations allocated space in the SOOS or SAC must abide by the policies in regard to use of office or storage space. Inquiries regarding office and storage space can be made by contacting Leadership, Service, and Civic Engagement by email at [email protected] Office and storage space requests are reviewed annually by the Leadership and Engagement and recommendations for assignment of space are made to the Associate Director of Leadership, Service, and Civic Engagement. Sport Clubs are required to follow all policies in regard to storage space established by Recreational Services.

Student Organizations

• Administration of Registered Student Organizations
• Discipline of Registered Student Organizations

SI-1: System And Information Integrity Policy And Procedures

Control family:.

System And Information Integrity

• P1: Implement P1 security controls first.

CSF v1.1 References:

Pf v1.0 references:, next version:.

• NIST Special Publication 800-53 Revision 5:
• SI-1: Policy and Procedures

Control Statement

The organization:

• A system and information integrity policy that addresses purpose, scope, roles, responsibilities, management commitment, coordination among organizational entities, and compliance; and
• Procedures to facilitate the implementation of the system and information integrity policy and associated system and information integrity controls; and
• System and information integrity policy [Assignment: organization-defined frequency]; and
• System and information integrity procedures [Assignment: organization-defined frequency].

Supplemental Guidance

This control addresses the establishment of policy and procedures for the effective implementation of selected security controls and control enhancements in the SI family. Policy and procedures reflect applicable federal laws, Executive Orders, directives, regulations, policies, standards, and guidance. Security program policies and procedures at the organization level may make the need for system-specific policies and procedures unnecessary. The policy can be included as part of the general information security policy for organizations or conversely, can be represented by multiple policies reflecting the complex nature of certain organizations. The procedures can be established for the security program in general and for particular information systems, if needed. The organizational risk management strategy is a key factor in establishing policy and procedures.

Related Controls

Nist special publication 800-53 revision 4.

• PM-9: Risk Management Strategy

Cloud Controls Matrix v3.0.1

• AIS-04: Data Security / Integrity
• AAC-03: Information System Regulatory Mapping
• BCR-10: Policy
• CCC-04: Unauthorized Software Installations
• DSI-04: Handling / Labeling / Security Policy
• GRM-06: Policy
• GRM-08: Policy Impact on Risk Assessments
• GRM-09: Policy Reviews
• IAM-05: Segregation of Duties
• IAM-07: Third Party Access
• TVM-02: Vulnerability / Patch Management