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Handbook of Operating Procedures

Protection from Retaliation

Policy Number: 108


Prohibiting unlawful retaliation against employees, students and trainees (residents and fellows) as a consequence of good faith actions in the reporting of, or the participation in an investigation pertaining to, allegations of wrongdoing.


Employees, students and trainees

Date Reviewed:
August 2020
Responsible Office:
Office of Institutional Compliance
Responsible Executive:
Assistant Vice President and Chief Compliance Officer


The University of Texas Health Science Center at Houston ("university") is committed to including employees, students and trainees in the process of ensuring that the university operates in an ethical, honest, and lawful manner. The policy of the university is to:

  1. Encourage employees, students and trainees to report, or cause to be reported, and to assist in any investigation by persons authorized or responsible for such matters, known or suspected violations of laws, rules, policies, or regulations, or improper activities; and
  2. Prohibit retaliation against employees, students and trainees as a consequence of good faith actions in the reporting of, or the participation in an investigation pertaining to, allegations of wrongdoing.

The purpose of this policy is to provide requirements and guidelines for the protection of individuals from retaliation for good faith actions in reporting, or participating in an investigation pertaining to, alleged violations of laws, rules, policies, procedures, or improper activities applicable to the university.


Retaliation: A materially adverse action against an individual for making a good faith report, or participating in an investigation, of alleged wrongdoing.


     A.     Procedures for Reporting Retaliation

         1.     Designation of Responsible Party for Retaliation Complaints

The Chief Compliance Officer (“CCO”) shall be the responsible party for the oversight of the implementation of this procedure.

         2.      Responsibility to Report Allegations of Retaliation

The responsibility of all employees, students and trainees is to make a good-faith report of any activity that appears to be in violation of this policy. A good-faith report is an allegation made with the honest belief that the activity reported may have occurred. An allegation is not in good faith if it is made with reckless disregard for or willful ignorance of facts that would disprove the allegation. Persons making disclosures with reckless disregard for the truth or in willful ignorance of the facts may be subjected to disciplinary action, including termination or dismissal.

         3.      Submitting a Retaliation Complaint

A complaint alleging retaliation must be submitted in writing to the Office of Institutional Compliance (“OIC”). The complaint should contain the following information:

  • Name of the complainant;
  • Contact information, including address, telephone, and email address, if applicable;
  • Name of the person directly responsible for the alleged retaliation;
  • Date and place of the alleged retaliation;
  • Nature of the alleged retaliation;
  • Detailed description of the specific conduct that is alleged to constitute retaliation;
  • Copies of any documents pertaining to the alleged retaliation;
  • Names of any witnesses to the alleged retaliation;
  • Corrective action requested by the complainant; and
  • Complainant's acknowledgement of the above facts; and
  • Date of filing.

OIC may require the complainant to amend the complaint to provide sufficient information. If the complainant does not amend the complaint to correct the insufficiencies identified by OIC within a reasonable timeframe, as defined by OIC, the complaint may be dismissed by OIC.  Individuals filing a complaint under this policy may ask for confidentiality.  OIC will grant confidentiality to the extent possible.

The following communications do not constitute a retaliation complaint and will not be investigated or resolved pursuant to this policy:

  • Oral allegations;
  • Anonymous communications;
  • Courtesy copies of correspondence or a complaint filed with others;
  • Inquiries that seek advice or information only; and,
  • Pre-complaint consultations and informal resolution activities.

A written complaint must be filed as soon as reasonably possible, but no later than sixty (60) calendar days after the occurrence of the alleged retaliation.

     B.     Procedures for Investigating Reports of Retaliation

         1.      Acknowledgement and Notification of Receipt of Complaint

               a.         Complainant. The OIC will send the complainant a brief acknowledgment of the complaint, stating that the complaint will be evaluated, and advising the complainant that he or she will be contacted within a given period of time. The acknowledgment will include a copy of this policy. The complainant will be kept apprised of the status of the investigation of the matter, to the extent the OIC determines the communication does not compromise the integrity of the investigation.

               b.         Department Head. After receipt and evaluation (see Section III.B.2) of a written retaliation complaint, the OIC shall inform the relevant department head(s)/equivalent of the allegation. The OIC also shall keep the department head(s)/equivalent apprised of the status of the investigation of the matter. If the department head(s)/equivalent is the subject of the investigation, the OIC shall provide such information instead to that individual’s supervisor.

              c.         Respondent. The OIC shall inform the individual against whom the allegations are raised of the nature of the allegations and of the status of the investigation at the point and to the extent that the OIC determines that it will not compromise the integrity of the investigation.

          2.      Complaint Evaluation

The OIC will initiate an investigation if the written, acknowledged complaint contains all of the required information, is timely within the scope of this policy and states sufficient specific facts. These facts, if determined to be true, must support a finding that the non-retaliation provisions of this policy were violated. Notwithstanding that the complaint meets the foregoing requirements, the OIC may determine not to proceed with a complaint investigation for any one of the following reasons:

  • the complainant withdraws the complaint;
  • corrective action has been taken, or has been offered and rejected;
  • another complaint resolution process is more appropriate; or,
  • litigation or another complaint process is pending.

If the OIC determines not to proceed with a complaint investigation, it will send a notification to the complainant stating the reason for that determination.

          3.      Investigative Process and Findings

If it is determined that the university will proceed with a retaliation complaint investigation, the OIC or its designee (“investigator”) will interview the complainant, the respondent, and any other persons whom the investigator determines may have pertinent factual information related to the retaliation complaint. The investigator shall also gather and examine relevant documents.

University community members have a duty to participate in these investigations. Any person who knowingly and intentionally interferes with an ongoing investigation under this policy will be subject to disciplinary action, up to and including termination or dismissal.

Facts will be considered on the basis of what is reasonable to persons of ordinary sensitivity and not on the basis of a particular sensitivity or reaction of an individual. Findings will be based on the totality of circumstances surrounding the alleged retaliation.

During the retaliation complaint investigation process, the complainant and the respondent will provide the OIC or designee with all documents relied upon regarding the issues raised in the complaint.

          4.      Report of Findings and Recommendation; Final Determination

The investigator will provide a proposed statement of findings, copies of relevant documents, and relevant physical evidence to the CCO within thirty (30) working days of receipt of the respondent's statement, unless an extension to the deadline is granted by the CCO.  The CCO or designee and the investigator shall meet within ten (10) working days thereafter to discuss the findings.

Within fifteen (15) working days after that meeting, the CCO or designee shall take one of the following actions:

a. Request further investigation into the complaint;

b. Dismiss the complaint; or

c. Find that the non-retaliation provisions of this policy were violated, in which event the CCO or designee shall outline recommended action. The university shall take appropriate corrective action in accordance with university disciplinary policies.

The CCO or designee shall notify in writing the complainant, respondent, and appropriate department head(s) of his or her decision. The OIC shall retain copies of the CCO’s letter, the statement of findings, and relevant documents in accordance with the university’s records retention schedule.

Reports of retaliation and results of the investigations shall be brought to the attention of the Executive Compliance Committee. Institutionally significant reports, as deemed such by the CCO, may be brought to the attention of the Institutional Compliance Committee.

          5.      Substitution of Officers

If a retaliation complaint is directed against an official who would otherwise act on the complaint, the function assigned to that official in this policy will be delegated by the CCO or the President of the university, as appropriate, to another person.

          6.      Confidentiality

All participants should keep information regarding a retaliation complaint or investigation confidential, except as otherwise permitted or required by law.