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Handbook of Operating Procedures

Standards of Conduct

Policy Number: 109


Standards of Conduct


Employees, trainees (including students, residents and fellows), vendors and contractors

Date Reviewed:
June 2015
Responsible Office:
Office of Institutional Compliance
Responsible Executive:
Assistant Vice President, Chief Compliance Officer


The University of Texas Health Science Center at Houston ("University") expects all employees and trainees to follow the highest standards of personal conduct as established by University policy and federal, state and local laws.

Employees must also acknowledge they understand their responsibilities to review the policy and to perform their work in an ethical and legal manner as described in the Standards of Conduct Guide.

As a condition of enrollment, students are responsible for knowing and observing the University regulations concerning student conduct and discipline (see HOOP Policy 186 Student Conduct and Discipline).

The University reserves the right to take appropriate disciplinary action against any employee or trainee who fails to comply with, or fails to report suspected noncompliance with, policies and procedures of the University, federal health care program requirements, or other applicable local, state or federal laws or regulations.


Employees or trainees who encounter situations they believe violate provisions of the University's Handbook of Operating Procedures, federal health care program requirements or other applicable local, state or federal laws or regulations must immediately consult their supervisor, another member of management in their area, or the Chief Compliance Officer. Employees or trainees may also use the Compliance Hotline in confidence and anonymity. Any person with a concern regarding a breach of ethics or a possible compliance matter should notify the Chief Compliance Officer. Persons making disclosures with reckless disregard for the truth or in willful ignorance of the facts may be subjected to disciplinary action.

Violations of the provisions of this policy will be handled in accordance with the appropriate disciplinary policy.


The University encourages its employees and trainees to make good faith disclosures of University related misconduct. The University will not tolerate retaliation or threat of retaliation against those who make disclosures of actual or perceived misconduct. Acts or threats of retaliation in response to such disclosures may subject the person retaliating to disciplinary action, up to and including termination or dismissal. Refer to HOOP Policy 108 Protection from Retaliation.