A Guide to Excellence Through Integrity
The University of Texas Health Science Center at Houston Standards of Conduct Guide
Table of Contents
As a comprehensive health science university, the mission of The University of Texas Health Science Center at Houston (“university”) is to educate health science professionals, discover and translate advances in the biomedical and social sciences, and model the best practices in clinical care and public health. As we endeavor to achieve this mission, the university must uphold ethical, professional and legal standards to serve as the basis for our work. These standards are outlined in this Standards of Conduct Guide (“Standards of Conduct”). The most critical element to realize the success of these standards is you. Every university employee and trainee has a responsibility for upholding our Standards of Conduct. You should never hesitate to ask questions if something does not seem right to you.
As Chief Compliance Officer, I support the university’s Standards of Conduct and our commitment to compliance. I encourage each of you to familiarize yourself with the Standards of Conduct to safeguard the university’s reputation for excellence and integrity.
Karen K. Spillar, JD
Vice President of Enterprise Risk Management and Chief Compliance Officer
The University of Texas Health Science Center at Houston
As a comprehensive health science university, the mission of The University of Texas Health Science Center at Houston is to educate health science professionals, discover and translate advances in the biomedical and social sciences, and model the best practices in clinical care and public health.
We pursue this mission in order to advance the quality of human life by enhancing the diagnosis, treatment, and prevention of disease and injury, as well as promoting individual health and community well-being.
“Excellence above all” in the quest to be an acknowledged leader in the collaboration to treat, cure and prevent the most common diseases of our time through education, research and clinical practice.
Every employee and trainee is responsible for behaving ethically and for following the policies, laws and regulations which apply to the university. Each of us must be aware of the legal and ethical standards that apply to our responsibilities. We must perform our duties and responsibilities in accordance with the provisions of federal, state and local laws, regulations and policies; the Rules and Regulations of the Board of Regents of the University of Texas System (“UT System”); and the policies of the university. These responsibilities are outlined in HOOP 109, Standards of Conduct in the university’s Handbook of Operating Procedures.
This Guide to Excellence Through Integrity is the university’s Standards of Conduct Guide and provides a summary of the responsibilities and standards of ethics and conduct that apply to all employees and trainees. This guide does not cover every situation and does not state every applicable policy. If additional information is needed, it may be found in the university’s Handbook of Operating Procedures. The Handbook of Operating Procedures can be found online at https://www.uth.edu/hoop. Employees and trainees may also seek guidance on specific ethical or compliance issues by contacting the Office of Institutional Compliance at (713) 500-3294.
The purpose of the Institutional Compliance Program is to proactively promote compliance with all applicable laws, regulations, and policies. The compliance program strives to foster and help ensure ethical conduct and to provide education, training and guidance to all employees and trainees. These goals are accomplished through regular risk identification, training, monitoring and auditing of the effectiveness of compliance activity. The goals, purpose and elements of the Institutional Compliance Program are contained in the university’s Institutional Compliance Manual. Copies may also be obtained through the Office of Institutional Compliance.
Responsibility for oversight of the implementation of the Institutional Compliance Program rests with a multidisciplinary Executive Compliance Committee, consisting of the President; the Senior Executive Vice President, Chief Operating and Financial Officer; the Executive Vice President & Chief Academic Officer; the Senior Vice President, Finance and Business Services; the Medical School Executive Vice Dean for Clinical Affairs; and the Medical School Dean.
Compliance is both an institutional and an individual commitment at the university. As an employee/trainee, you commit to:
- maintaining a working knowledge of the laws, regulations, policies, rules and procedures which apply to your individual responsibilities or activities;
- completing any required compliance training in a timely manner;
- complying with the laws, policies and procedures which apply to your individual responsibilities or activities;
- upholding the highest legal and ethical standards in fulfilling your duties or participating in activities at the university; and
- addressing ethical or compliance issues or concerns.
Management personnel at every level are expected to set an ethical tone and to be role models for legal and ethical behavior in their departments. They should strive to create a departmental culture which promotes the highest legal and ethical behavior and encourages everyone in the department to voice concerns when they arise.
Management personnel are required to verify that all employees and trainees complete any required compliance training at the university.
Each employee and trainee has the responsibility to address ethical and/or compliance questions or concerns. Determining if you have an ethical or compliance issue can be complex. Follow the checklist below to determine if you have an ethical or compliance issue:
- Does the action comply with the university’s policies and procedures?
- Is the action legal?
- How would the action look to your family, friends and community if published on the front page of the newspaper or broadcast on the news?
- Is the action fair and honest?
If the answer to any of the above questions is no, you are required to report the action using any of the following mechanisms:
- Make a report through the normal administrative channels (i.e., reporting to the appropriate supervisor)
- Make a report through the Compliance Hotline (1-888-472-9868)
- Make a report to the Chief Compliance Officer, or other staff member of the Office of Institutional Compliance, either by letter, by telephone, by email or by meeting
- Make a report in an exit interview statement given upon the conclusion of employment at the university
- Make a report through the designated university Compliance email address: firstname.lastname@example.org
- Make a report through the designated “Web Reporting” website: www.lighthouse-services.com/compliance.uth.tmc
Employees and trainees are encouraged to contact the Chief Compliance Officer directly at (713) 500-3294 to confidentially discuss compliance questions or concerns.
The university has established a Compliance Hotline and a Web Reporting website. These mechanisms are intended to supplement regular communication channels. Employees and trainees are encouraged to call the Compliance Hotline with questions concerning ethical or legal conduct or to discuss potentially improper actions if they do not feel comfortable addressing these concerns through other listed channels. The caller is not recorded, traced or identified, and the caller is not required to furnish his/her name. Information provided to the hotline is treated as confidential to the extent permitted by law. Persons making disclosures with reckless disregard for the truth or in willful ignorance of the facts may be subjected to disciplinary action.
The university will not tolerate retaliation or threat of retaliation against those who make disclosures of actual or perceived misconduct. See HOOP 108, Protection from Retaliation. 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. If you believe you have been retaliated against for addressing an ethical or compliance concern, you should immediately contact the Chief Compliance Officer at (713) 500-3294.
What is the number for the Compliance Hotline?
What are the hours of the Compliance Hotline?
The Compliance Hotline is available 24 hours a day, seven days a week.
I have a concern that I want to address through the Compliance Hotline, but I am afraid that my supervisor will find out that I called the hotline. What should I do?
You should feel comfortable making a good faith report to the Compliance Hotline. All reports made to the Compliance Hotline are treated confidentially if requested by the caller. You may remain anonymous and not give your name when you call the Hotline or report on the website. Additionally, university policy protects you from retaliation. Applicable state and federal laws may protect you from retaliation as well.
What are some examples of retaliation?
Retaliation is a materially adverse action taken against an individual for making a good faith report or participating in an investigation of alleged wrongdoing. Examples of retaliation include:
- Giving unwarranted negative performance evaluations to the reporting employee.
- Transferring the reporting employee without legitimate business justification.
- Taking adverse salary actions against the reporting employee without legitimate business justification.
- Suspending, demoting, or dismissing the reporting employee without legitimate business justification.
Fraud is knowingly or willfully attempting to gain any benefit which does not belong to you. The UT System Fraud Policy, UT System Policy 118, specifies individual responsibilities and actions regarding the prevention and reporting of fraud.
Abuse is defined as any activity that results in excessive or unreasonable cost to the university, or other state or federal agencies.
The university is required by federal law to provide information to all of its employees, contractors and agents regarding the federal False Claims Act, administrative remedies for false claims and statements, the state False Claims Act and whistleblower protections under these laws. The federal and state False Claims Acts play an important role in detecting fraud, waste and abuse in federal health care programs.
The federal False Claims Act was enacted to prevent the United States government from paying federal funds for fraudulent claims involving a good or a service. The law allows a civil action to be brought against a health care provider who:
- Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval to any federal employee;
- Knowingly makes, uses or causes to be made or used a false record or statement to get a false or fraudulent claim paid; or
- Conspires to defraud the government by getting a false or fraudulent claim allowed or paid.
False claims include knowingly:
- Billing for procedures not performed
- Falsifying information in a medical record
- Authorizing duplicate billing
- Falsifying claim forms to receive overpayment for services provided
Federal False Claims Act remedies include:
- A federal false claims action may be brought by the U.S. Department of Justice Civil Division.
- The False Claims Act allows a private individual or whistleblower, with knowledge of past or present fraud on the federal government, to sue on behalf of the government to recover stiff civil penalties. This is known as a Qui Tam case. If the government joins the lawsuit and prosecutes the entity suspected of fraudulent conduct and collects money which must be paid back to the federal government, the private individual who brought the suit, known as the Qui Tam Relator, is eligible to receive 15-25% of the proceeds of the recovery, depending upon the extent to which the Qui Tam Relator contributed to the prosecution of the action.
- Violation of the federal False Claims Act is punishable by a civil penalty of between $5,500 and $11,000 per false claim, plus three times the amount of damages incurred by the government.
- A statute of limitations limits the amount of time that may pass before an action may no longer be brought for violation of the law. Under the federal False Claims Act, the statute of limitations is six years after the date of violation or three years after the date when material facts are known or should have been known by the government, but no later than ten years after the date on which the violation was committed.
Federal law prohibits an employer from discriminating or retaliating against an employee in the terms or conditions or his or her employment because the employee initiated or otherwise assisted in a false claims action. The employee is entitled to all relief necessary to make the employee whole. This relief includes reinstatement with the same seniority status, two times the amount of back pay, interest on the back pay, and/or compensation for any special damages sustained as a result of the discrimination.
Texas has a state version of the False Claims Act that is substantially similar to the federal False Claims Act.
Offenses under the Texas False Claims Act are, in general, similar to those of the federal False Claims Act. However, under the Texas False Claims Act, a person may also be liable if he or she presents a claim for payment under the Medicaid program for a product or service that was rendered by an unlicensed provider or that has not been approved by a healthcare practitioner. The Texas False Claims Act also differs from the federal False Claims Act in that the civil penalty is greater for unlawful acts that result in injury to an elderly person, a disabled person or someone younger than eighteen.
The Texas False Claims Act has a whistleblower provision that prevents employers from retaliating against employees who report their employer’s false claims. Texas also has several other false claims statutes that are intended to prevent fraud and abuse in the Texas Medicaid program. These laws generally prohibit the filing of any false or fraudulent claim or documentation in order to receive compensation from the Texas Medicaid program.
The university is committed to providing high-quality patient care and to complying with applicable laws and regulations. All claims for professional fee reimbursement made by or on behalf of the university shall adhere to applicable federal, state and local laws and regulations, The UT System Board of Regents’ Rules and Regulations, and university policies (including UT Physicians, MSRDP and DSRDP policies). The university will follow all legal and regulatory guidelines for billing hospital and physician services. Any contractors engaged to perform billing or coding services are expected to ensure that all billings for government and commercial insurance programs are accurate. The university shall collect only those amounts to which the institution is entitled and shall refund amounts billed and/or collected in error. Failure to abide by the applicable federal and state laws and regulations, The UT System Board of Regents’ Rules and Regulations and university policies may lead to disciplinary action, up to and including termination or dismissal.
Unacceptable billing practices include, but are not limited to:
- Billing for items or services not accurately documented in the medical record;
- Billing for items or services that were not actually rendered;
- Billing for items or services that were not medically necessary; and
- Duplicate billing.
If you believe any unacceptable billing practices have occurred or have any billing compliance concerns, you should discuss the issue with your supervisor, contact the Office of Institutional Compliance at (713) 500-3294, or contact the Compliance Hotline at 1-888-472-9868.
All individuals who are employed by, affiliated with, under a contract or agreement, or otherwise under the control of the university, are required to report any activity that appears to be in violation of any local, state or federal law, including the federal or state false claims acts through the normal administrative channels or any other reporting paths described in these guidelines.
Possible federal false claims act violations are not required to be reported to the university first. Reports may be made directly to the federal Department of Justice or through the U.S. Health and Human Services Office of Inspector General Hotline number, 1–800–447–8477 (1–800–HHS–TIPS).
You may also report suspected fraud, waste and abuse to the State Auditor’s Office Hotline, 1– 800– 892– 8348 (1– 800–TX–AUDIT). The State Auditor’s Office provides additional information at its website (http://sao.fraud.state.tx.us).
The State of Texas and the Board of Regents of The UT System have defined certain ethical standards that apply to employees of the UT System. For further information, consult the UT System Office of General Counsel UT System’s Ethics Standards.
Does the university have an Ethics Officer?
Yes, the Chief Legal Officer also serves as the university’s Ethics Officer. You are encouraged to contact the Ethics Officer at (713) 500-3268 with any ethical questions or concerns you may have.
Where can I get a copy of the UT System Ethics Policy?
You can access the Ethics Policy via the internet. The Office of Legal Affairs also maintains copies of the UT System Ethics Policy. You may request a copy by calling (713) 500-3268.
A conflict of interest exists when university employees owe a professional obligation to the university that is or might be compromised by the pursuit of outside interests. Outside interests, such as professional activities, personal financial interests, or the acceptance of gifts from third parties, can create conflicts of commitment or conflicts between the interests of the university and university employees’ private interests and may prevent university employees from making decisions that are in the best interest of the university. Even if those outside interests do not actually impair university employees’ ability to act in the best interest of the university, it may appear to the public that independence of judgment has been affected. For more information, consult HOOP Policy 20 Conflicts of Interest, Conflicts of Commitment and Outside Activities.
I am a department head and have been working with a university vendor for several years. This vendor recently offered to do some landscaping work for me at a discount. Can I let him landscape my yard?
No. A discount would mean that the vendor is giving you a benefit with the expectation that you will provide continued or more university business for this vendor.
If I own stock in UPS and my department ships packages via UPS, does a conflict of interest exist?
No. Investments in publicly traded companies such as UPS are not considered to be conflicts of interest.
Can employees benefit financially from books or other writings that were purchased with university funds?
No. Royalties from books, scholarly works or other writings that are purchased with university funds may not be retained by employees. Employees must account for, and remit to the university, all royalties or like compensation received for any such purchases.
A student with constant billing problems frequently visits the Bursar’s Office for assistance. The student wants to tip the Cashier $100. Can the Cashier accept the gift?
No. Cash gifts must never be accepted from anyone with whom the university has a business relationship.
One of the vendors we deal with in our department wants to take me to lunch to discuss their new product line. Is it okay to accept the invitation?
You may accept the invitation if going to lunch with the vendor will not tend to influence your decisions, you are the guest of the vendor, and the vendor is present. However, you cannot go to lunch and use a vendor’s account at the restaurant if the representative is not present. You should, however, pay for your own meal to avoid the appearance that the lunch influenced your choice of vendors or products for the university.
There are two standards under Texas law governing gifts: (1) a general standard of conduct that applies to all employees and (2) a criminal standard that applies only to those persons who make recommendations or decisions about contracts and other financial transactions.
Under the general standard, university employees may not accept or solicit any gift, favor or service that might reasonably tend to influence their discharge of official duties. Furthermore, university employees may not accept or solicit any gift, favor or service they know or should know is being offered with the intent to influence official conduct. This standard applies even when the donor is not asking for anything in exchange for the gift. A gift is anything of value, including tickets to entertainment or sporting events, expenses for a trip, and food. Acceptance or solicitation of a gift in violation of this standard is not a criminal offense but is grounds for disciplinary action, up to and including termination.
Under the criminal standard, criminal penalties may apply to persons who make recommendations or decisions about university financial transactions. University employees who make recommendations or decisions about university financial transactions, such as purchases and contracts, may not accept a gift from an individual or entity that is interested in or likely to become interested in that transaction, with limited exceptions. Under those exceptions, it is not a criminal offense to accept any of the following type of gifts so long as the gift is not given in exchange for official action :
- Gifts of non-cash items worth less than $50.
- Gifts from a person such as a relative, friend or business associate with whom the university employee has a relationship independent of their official status, if the gift is given on account of that relationship rather than their official status.
- Gifts of food, lodging, transportation or entertainment in any amount if the employee accepts them as a “guest,” which means the donor must be present.
Acceptance of a gift in exchange for official action is never lawful. Note that even if acceptance of a gift is permissible under the criminal standard, it may still be prohibited under the general standard if the gift is given to influence a university employee’s official duties.
Additional restrictions apply if the gift is from a student loan lender. The definition of “student loan lender” is very broad and covers entities that may not traditionally be thought of as student loan lenders. Consult the Office of Institutional Compliance or UT System’s Office of General Counsel to determine if the proposed gift from the student loan lender is permissible under UT System Policy 171 - Student Financial Aid Code of Conduct.
University employees should not accept other employment or compensation that could reasonably be expected to impair their independence of judgment in performing official duties. The primary responsibility of university employees is the accomplishment of the duties and responsibilities assigned to their position at the university. External consulting, outside employment or other activities that interfere with those duties and responsibilities should not be accepted. At the same time, the university recognizes the benefits of employees’ participation in outside activities that clearly enhance the mission of the university and/or provide important elements of employee development related to their university responsibilities. This may include consultative or advisory activities with governmental agencies, other institutions, or private industry that are not in conflict with the proper discharge of their duties and responsibilities in the public interest. In keeping with the university’s mission of education, research and clinical practice, the university believes these outside activities have the potential to improve the performance of an employee through continuing contact with issues/problems in the non-academic fields that promote the university’s mission.
In general, full-time faculty members may devote up to fifty (50) working days in any fiscal year to activities that clearly contribute to the mission of the university and/or provide important elements of faculty development related to their university responsibilities, so long as these activities are not in conflict with the proper discharge of their duties and responsibilities in the public interest. Examples include acting in an editorial capacity for a professional journal, attending and presenting talks at scholarly colloquia and conferences, and serving as a committee member, officer, or board member of a professional or scholarly society. This 50 working day time threshold also applies to service on a federal, state, or local government agency committee, panel, or commission (e.g., NIH review panel); professional collaborations (related to the faculty member’s university responsibilities) with other institutions of higher education or with an academic teaching hospital, medical center, or research institute affiliated with an institution of higher education; and reviewing journal manuscripts,book manuscripts, or grant or contract proposals for external non-US government agencies or foundations.
All employees must obtain prior approval before engaging in outside activities, except as listed above, and obtain re-approval on an annual basis in the online system (Outside Activities Request Form). For part-time employees with less than a 50% appointment, the requirement to obtain prior approval for outside activities is at the discretion of each school or operating unit, provided that such activities do not cause a substantial conflict with proper discharge of the employee’s duties for the university. Supervisors have the right to limit an employee’s outside activities if they conflict with the ability of the employee to perform the obligations of his or her university responsibilities. For more information, consult HOOP Policy 20 Conflict of Interest, Conflict of Commitment and Outside Activities.
A university employee may not accept an honorarium in consideration for services that the employee would not have been requested to provide but for the employee’s official position or duties. For example, employees may not accept a gift or payment for giving a speech if they would not have been asked to provide the speech but for their official position. However, meals, transportation and lodging may be accepted in connection with such services so long as the services are more than merely perfunctory or superficial. Gifts of very minimal value may be accepted for such services, such as a plaque or coffee cup.
I have been asked to give a speech regarding the paper I published this spring in the Journal of the American Medical Association. The director stated that I was asked to speak at the conference because of my research work. I have been offered a small honorarium to give the speech along with reimbursement for my food, transportation and lodging. Can I accept the honorarium? What about the food, transportation and lodging?
I am the head of the purchasing department and was invited to speak at a conference because of my position at the university. I have been offered a small honorarium along with reimbursement for my food, transportation, and lodging. Can I accept the honorarium? What about the food, transportation and lodging?
You cannot accept the honorarium because your position with the university is one of the reasons you were asked to give the speech. However, you may accept the reimbursement for your food, transportation and lodging expenses. Tex. Penal Code §36.07.
University employees may not make personal investments that could reasonably be expected to create a substantial conflict between their private interest and the public interest. University employees should not have a substantial direct or indirect financial interest in a business that conflicts with university interests or that might influence how they do their job. Some financial interests may be so indirect or so minimal that they do not create conflicts of interest, such as ownership of a minimal amount of stock in a company or an investment in a publicly traded mutual fund in which the employee does not exercise discretion regarding the investment of the assets of the fund. If uncertain as to whether a particular investment creates a conflict of interest, university employees should ask their supervisors or consult with the Office of Institutional Compliance.
If employees have an interest in a business that might constitute a conflict of interest, they should disclose that interest in accordance with HOOP 20. In some cases, the conflict may be cured by that employee not participating in any decision concerning that business. However, if the conflict is significant, the employee may be required to divest of the interest that causes the conflict.
You have been buying stock in a company that does business with the the university. After your next purchase you will own 10% of the company. Is this a conflict of interest?
Potentially. If you have the authority to award contracts, select vendors or influence the purchases of goods and services, you must report your ownership in accordance with HOOP 20.
University employees may not transact any business in an official capacity with any business entity of which they are an officer, agent, or member, or in which they own a substantial interest.
Additionally, before the university may purchase any supplies, materials, services, equipment, or property from a university employee, the President or his designee must approve the purchase, and the purchase may be made only if the cost is less than from any other known source. For additional information, refer to HOOP Policy 126 Purchases from and Sales to Employees.
The university strives to create a research climate that promotes faithful adherence to high ethical standards in the conduct of research without inhibiting the productivity and creativity of all persons involved in research. These standards require the protection of scientific integrity, human subjects and research animals. These standards also require responsible data management and authorship. Employees and trainees must keep a permanent record of all experimental protocols, data, and findings in accordance with the university’s Records Retention Schedule. Co-authors on research reports of any type must have a bona fide role in the research and must accept responsibility for the quality of the work reported. For more information, consult HOOP Policy 168 Conduct of Research and HOOP Policy 181 Records Management Program.
What behavior is considered scientific misconduct?
Fabrication, falsification, plagiarism or other practices that deviate from those that are commonly accepted within the academic community for proposing, reviewing, conducting or reporting research. Honest errors or honest differences in interpretations or judgments of data do not violate HOOP 202, Research Misconduct.
How do I report scientific misconduct?
You should report any allegations of dishonesty, misconduct, or fraud in research to the Research Integrity Officer, as defined in HOOP 202. If the allegations involve a department chair or dean, they should be reported to the Executive Vice President & Chief Academic Officer. For more information, consult HOOP Policy 202 Research Misconduct.
The university respects the privacy of every patient. Patients expect the information they give to their health care providers to remain confidential and protected. If patients do not feel the information they give to their health care providers is respected and protected, patients may not be forthcoming with information. Withholding information could have a drastic and adverse effect on the treatment the patient receives and on the outcome of research based on patient data.
The Privacy Office has developed policies and procedures regarding the use and disclosure of protected health information and patients’ rights. Further information can be found at http://www.uth.tmc.edu/hipaa/ and in HOOP 206, Privacy of Individually Identifiable Health Information. Contact the Privacy Office at (713) 500-3391 for specific questions.
Employees or trainees who have patient questions related to research can also contact the Committee for the Protection of Human Subjects.
Sensitive information about university students, employees, strategies, and operations must be protected. Employees who handle sensitive information shall follow all administrative, technical, and physical safeguards implemented by the university for the protection of sensitive information. To the extent applicable, the same provisions shall apply to protection of the sensitive information of distance education students.
An employee or trainee may use or request sensitive information to fulfill his or her responsibilities. However, that information must not be shared with others, inside or outside of the university, unless the individuals have a legitimate business need to know and the information is shared in compliance with the applicable laws, regulations, policies, and procedures.
Sensitive information may include:
- Personnel data
- Social security numbers
- Student information (see HOOP 129, Educational Records),
- Patient information,
- Research data,
- Financial data,
- Strategic plans,
- Marketing strategies,
- Employee lists and data,
- Supplier and subcontractor information, and
- Proprietary computer software.
1. Email Transmission of Sensitive Information
University employees, trainees and contractors are required to obtain a digital ID if they transmit or receive confidential information across the internal university network or public network. They must digitally sign electronic documents and/or require access to restricted resources requiring strong authentication. For more information, consult ITPOL-023.
2. Confidential Nature of Social Security Numbers
All employees must comply with the provisions of UT System Policy 165 Information Resources Use and Security Policy which includes the following provisions:
- Employees must inform individuals when they collect social security numbers and provide appropriate notice;
- Employees may not request disclosure of a social security number if it is not necessary and relevant to the purposes of the university and the particular function for which the employee is responsible;
- Employees may not disclose social security numbers to unauthorized persons or entities;
- Employees may not seek out or use social security numbers relating to others for their own interest or advantage; and
- Employees responsible for the maintenance of records containing social security numbers shall observe all institutionally-established administrative, technical and physical safeguards in order to protect the confidentiality of such records.
- Unless the university is legally required to collect a social security number, an individual may not be required to disclose his or her social security number, nor shall an individual be denied access to services if he or she refuses.
While viewing some employment records, I noticed that a new employee is married to my ex-husband. Can I go talk to her about it?
No. You may not disclose that you saw this information on her employment application. The employment application contains sensitive personnel information. If you speak with the new employee about the information in her employment application, you are not fulfilling your responsibility to maintain the confidentiality of this information.
My students just finished taking their mid-term exams. I would like to post their grades with their social security numbers instead of their names to protect the students’ identity. Is this okay?
No. Grades may not be publicly posted or displayed using the students’ social security numbers. A better practice would be to post the students’ grades with their student identification numbers, so long as the student identification number cannot be identified with the student associated with that number.
The university is committed to providing a safe and healthy workplace environment. University employees are encouraged to treat each other in a fair and respectful manner. The university, in accordance with applicable federal, state and local laws and regulations, prohibits discrimination on the basis of race, color, national origin, sex, sexual orientation, age, religion, disability or veteran status in any of its policies, practices and procedures. All employment-related decisions will reflect this commitment.
In all matters related to employee or trainee status, the policy of the university is to provide equal opportunity without regard to race, color, religion, age, national origin, sex, sexual orientation, disability, genetic information, gender identity or expression, veteran status or any other basis prohibited by law. Further, the policy of the university is to provide an environment free from verbal, physical, and/or visual forms of discrimination or harassment. For further information, consult HOOP Policy 183 Nondiscrimination, Anti-Harassment and Equal Opportunity.
I feel that I was passed up for a promotion because of my age. Who do I call if I feel I have been discriminated against?
Diversity & Equal Opportunity manages all allegations of discrimination. If you feel you have been discriminated against, contact Diversity & Equal Opportunity at (713) 500-3130.
The university is committed to providing an environment free from discrimination and inappropriate conduct, which includes all forms of sexual misconduct, including sexual harassment. Employees and trainees who engage in such conduct will be subject to disciplinary action, up to and including termination or dismissal. Complaints or reports alleging that a member of the university community is a victim of sexual misconduct should be reported to the Title IX Coordinator at 713-500-3131 or at UCT Suite 150. Complaints may also be reported via the Compliance hotline (1-888-472-9868). Resources are available to conduct a thorough investigation that protects the rights of all involved parties. For more information, employees should consult HOOP Policy 59, Sexual Misconduct.
What are examples of behavior that could be considered sexual misconduct or sexual harassment?
Behavior that could be considered sexual misconduct or harassment includes but is not limited to: physical contact of a sexual nature including touching, patting, hugging, or brushing against a person’s body; explicit or implicit propositions or offers to engage in sexual activity; comments of a sexual nature including sexually explicit statements, questions, jokes or anecdotes, remarks of a sexual nature about a person’s clothing or body, remarks about sexual activity, or speculation about sexual experience; and, exposure to sexually oriented graffiti, pictures, posters or materials.
The university strives to comply with all provisions of the Fair Labor Standards Act (FLSA). The FLSA is a federal law which requires payment to non-exempt employees of overtime pay or compensatory time off for all hours worked in excess of 40 in a work week. In general, employees who are covered by the FLSA at the university are classified employees. Faculty are exempt employees. The university requires non-exempt employees to obtain supervisory approval prior to working overtime. For more specific information, refer to HOOP Policy 154 Overtime Pay and Compensatory Time Off.
I worked sixty hours last week due to a project that had to be completed by the end of the week. Am I eligible for overtime pay or compensatory time off?
You may be eligible for overtime pay or compensatory time off if your position is covered by the FLSA. You must obtain your supervisor’s approval prior to working overtime. For more information, contact Compensation Services in the Office of Human Resources at (713) 500-3130.
The university requires all employees to submit records reflecting their hours absent from work and, in the case of hourly salaried and non-exempt employees, their hours worked. Employees should submit their time records in the online time management system in accordance with the schedule outlined in HOOP Policy 24 Time and Attendance Reporting. For specific questions regarding the university’s online time management system, consult the designated timekeeper in your department or contact Payroll at 713-500-3962.
The university acknowledges that employees may need time to attend to personal or family medical needs for serious health conditions, the birth, adoption, or placement of a baby or military service of a family member. HOOP Policy 106 Family and Medical Leave details how an employee may obtain leave in these circumstances. Employees should also consult an Employee Relations Advisor in the Office of Human Resources at (713) 500-3130.
When am I eligible to apply for Family and Medical Leave?
You are eligible to apply for Family and Medical Leave after you have been employed by a State of Texas agency for the past 12 months and have worked at least 1,250 hours at the university.
How much time is available under the Family and Medical Leave policy?
A maximum of 12 work weeks during a 12-month period is available under the Family and Medical Leave Policy. A maximum of 26 work weeks during a 12-month period may be available for employees caring for a covered servicemember.
Each employee is responsible for protecting and preserving university property, equipment and supplies. The conservation of state resources is a responsibility that university employees, as state employees, hold as trustees for the citizens of the State of Texas. Public resources may not be used for personal benefit or gain.
Limited use of university resources for personal purposes, such as telephone calls and email, is permitted under the following circumstances:
- The use does not result in a cost to the university;
- The use does not interfere with job duties and responsibilities;
- The use is brief in duration;
- The use does not disrupt or distract from the conduct of official business;
- The use does not compromise the security or integrity of private confidential information.
University resources may never be used:
- To conduct an outside business;
- To campaign for or support a campaign for political purposes;
- For illegal activities;
- To support, promote or solicit from an outside organization or group unless approved in advance.
My child calls me at work when he gets home from school to let me know he is okay. Is this a permissible use of a university resource?
Yes. As a general rule, the personal use of any university property or asset is prohibited. Incidental personal use of email, the telephone or the internet that complies with applicable university policies, and does not result in additional cost to the university is permissible. For example, using your long distance access code to utilize the university’s long distance service to make a personal long distance call is prohibited because this would result in additional cost to the university. For more information, consult HOOP 180, Acceptable Use of University Information Resources; ITPOL-019.
I have a personal email account that is available via the internet that I would like to check at work. Is this permitted?
The internet should only be used for legitimate state business. However, brief and occasional internet browsing of a personal nature is acceptable so long as the use conforms to the permissible use and prohibited use sections of HOOP Policy 180 Acceptable Use of University Information Resources. Only incidental amounts of employee time – time periods comparable to reasonable coffee breaks during the day – should be used to attend to personal matters. All internet access is logged and could be subject to further review.
I tried to access an internet site for work purposes and a block screen appeared with a display informing me that the site potentially violated university policy . What should I do?
The block screen is triggered when sites that could potentially violate university policy are accessed. If you have a legitimate mission-related reason to access the site, you may do so by certifying the need. The certification process requires users to enter their university username and password at the time of access. If you do not know your university username and password, you should contact the Information Services Helpdesk at (713) 500-4848.
Employees may participate in political activities if the activities:
- Are not conducted during work hours, unless the employee uses accrued compensatory or vacation leave;
- Are in compliance with the Constitution and the laws of the State of Texas;
- Do not interfere with the discharge of the employee's duties and responsibilities;
- Do not involve the use of equipment, supplies, or services of the UT System or the university;
- Do not involve the impermissible use of UT System or university resources and facilities;
- Do not involve the attempt to coerce other students or employees to participate in or support the political activity; and
- Do not involve the UT System or the university in partisan politics.
For more information, consult HOOP Policy 38 Political Activity.
Political contributions from any source of university funds are prohibited.
My friend is running for office. Is it okay to email some of my co-workers and friends to let them know about a campaign event?
No, a state employee cannot use state time or property, such as computers and the email system, for political purposes.
Is it okay to bring my friend to our next mandatory staff meeting so she can meet my co-workers and tell them about her campaign?
No. It is not appropriate to force other university community members to participate in any political activities. Bringing your friend to the mandatory staff meeting would be considered forcing other university community members to participate in a political activity as well as using university time for political purposes.
Only individuals expressly authorized in writing by the university President may enter into contracts or agreements, either oral or written, on behalf of the university. No individual may sign a contract on behalf of the university unless expressly authorized to do so in writing by the university President. For more information, consult The UT System Board of Regents' Rules and Regulations for Procurement of Certain Goods and Services and HOOP Policy 124 Authority to Execute Contracts and Make Purchases.
My department is having an event and has asked me to make the arrangements. I want to sign a contract with the restaurant providing food for the event. May I do so?
No, unless you have official authority to do so. The Office of Legal Affairs maintains a list of those persons authorized to bind the university through a contract or agreement. You may contact them with questions at (713) 500-3268. Furthermore, this is a contract for purchasing goods and services and must be approved by Procurement Services prior to it being signed.
Employees may not use university funds for any purchase unless the person is authorized to make the purchase in accordance with the Regents’ Rules and Regulations, Series 10501, Delegation to Act on Behalf of the Board, and the purchase is made in accordance with all institutional purchasing procedures. The Regents’ Rules and Regulations may be accessed through the internet at http://www.utsystem.edu/board-of-regents/rules. For more information, consult HOOP Policy 124 Authority to Execute Contracts and Make Purchases.
Our department wants to purchase new furniture. Can we go to any store and purchase the furniture and seek reimbursement?
No. The university has strict guidelines for purchasing. Purchases over a certain amount must be placed for bid and should include historically underutilized vendors. For more information, contact Procurement Services at (713) 500-4700.
The software installed on university owned computers is licensed to the university for specific uses and purposes. No software licensed to the university may be copied unless authorized by the software licensor. Copying software that is licensed to the university to do university work on a personal home computer is not permitted, unless expressly authorized in the license agreement. If you have questions, contact your supervisor, your IT support staff, or the Office of Information and Technology Services at (713) 500-2221. You may also consult HOOP 180, Acceptable Use of University Information Resources and ITPOL-18.
I have a program installed on my computer which my co-worker does not have installed on her computer. We are working on a project together and she needs this software program in order to help me finish the project. Can we copy the software off of my computer and install it on her computer?
No, before you copy the software, you must make sure that the use of the software in this manner is permitted by the license. Contact your supervisor, your IT support staff, or the Office of Information Services before you copy the software to make sure that it is allowable.
Computer passwords should be considered highly confidential. You should never disclose your computer passwords to anyone. Furthermore, you should not write or otherwise document passwords in a place that is accessible by others. For more information contact Information Technology.
When I was out of the office yesterday with a cold, I called the office and asked another employee to check my email and calendar. To do this, I had to reveal my password. Was this wrong?
Yes, it is a violation of university policy to disclose your computer password. Computer passwords should be considered highly confidential and should not be disclosed to anyone. When passwords are revealed, data that is protected by passwords becomes vulnerable to damage, theft or unauthorized disclosure. If you need to check your email or calendar from home, you should make use of webmail. You can access webmail through the Internet at https://webmail.uth.tmc.edu/. If you do not have access to a computer at home to access webmail, you can configure your calendar to allow others to view it. Contact your supervisor, your IT support staff or the Office of Information Services if you need further information or assistance.
Intellectual property is any invention, discovery, trade secret, technology, scientific or technological development, computer software, or other form of expression that is in a tangible form. Intellectual property can be protected by patent, trademark or copyright laws, or it can be protected by not disclosing the information to others.
The university’s Office of Technology Management (“OTM”) provides a resource to university inventors to explore the possibilities of their creations, to facilitate technology transfer activities that bring new discoveries to the people of Texas and to generate financial benefits for the university and its inventors.
Intellectual property either developed within the course and scope of university employment of the individual or resulting from activities performed on UT System time, or with support of State funds, or from using facilities or resources owned by the UT System or any of its universities (other than incidental use) is automatically owned by the Board of Regents. The course and scope of employment includes outside activities related to the employee’s area of expertise. This applies to (1) all persons employed by the university, including but not limited to full and part-time faculty and staff and visiting faculty members and researchers and (2) to anyone using the facilities or resources of the university, including but not limited to students, residents, participants in certificate programs or collaboration programs, or postdoctoral and predoctoral fellows.
Intellectual property resulting from research supported by a grant to the university or The UT System belongs to the university or The UT System.
When intellectual property is created by a university employee or other individual described above, the creator must disclose the intellectual property to the OTM. Disclosure of an invention or discovery by publication or presentation to the public or industry before disclosure to the university’s OTM is a violation of UT System Board of Regents Rules and Regulations Rules for Intellectual Property.
For more information on how to disclose an invention or discovery, contact OTM at (713) 500-3369 or https://www.uth.edu/otm/. OTM can also provide information on patent protection for an invention or discovery and the university’s royalty distribution policy.
For more information consult UT System Board of Regents Rules and Regulations 90001, Intellectual Property: Preamble, Scope, Authority or HOOP 201 Intellectual Property.
I submitted a manuscript for publication in a scientific journal on a development that may be patentable. What is the next step?
A Technology Report Form should be submitted to ’s OTM prior to submission of a manuscript or abstract for publication or presentation. Public disclosure prior to protecting the invention may result in loss of certain patent protection. For more information, contact OTM at (713) 500-3369 or https://www.uth.edu/otm/.
Copyrighted material is material produced by someone who has restricted its use. To reproduce the material, you must have the permission of the owner or copyright holder. It is best to assume that most books, magazines and other materials are copyrighted and are prohibited from being photocopied. For more information consult HOOP Policy 47 Classroom and Research Use of Copyrighted Material. For specific guidance, consult the Copyright Guidelines of the HOOP.
I want to copy an article in a scientific journal I subscribe to, to distribute to my students for discussion in our next class. Is that permissible?
Multiple copies may be made for classroom use or discussion provided that each copy includes a notice of copyright, the copying meets the tests of brevity and spontaneity defined in the Copyright Guidelines, and the copying meets the cumulative effects test defined in the Copyright Guidelines. Faculty members are encouraged to review the Copyright Guidelines and become familiar with them. For assistance, contact the OTM at (713) 500-3369.
Employees of the university are responsible for maintaining the integrity and accuracy of university business documents and records for which they are responsible. Employees may not alter or falsify information on any university record or document. For more information, consult the Texas Penal Code § 37.10.
I noticed that some numbers were wrong on a document I sent out. Can I go back and change the numbers so that my file copy is correct?
No. Changing the numbers may be considered altering or falsifying the document. If possible, reissue the document and indicate the revisions.
The university is required by state law to maintain an active and continuing records management program that identifies vital and confidential records and ensures the appropriate retention and disposition of records. No employee or trainee should tamper with records or remove or destroy them, except in accordance with the approved retention and disposition policy. Questions about specific record retention requirements should be directed to the university’s Records Management Department at (713) 500-8508 or (713) 500-8123. For further information, consult HOOP Policy 181 Records Management Program.
My department is very low on file space, and I need to throw away old files to make room for new ones. Can I throw away everything that is greater than three years old?
No. The university has a formal records retention schedule that should be followed by everyone. The Records Retention Schedule details what records must be kept and for how long. If you have any questions, you should contact the university’s Records Manager at (713) 500-8508 or (713) 500-8123.
I have over 1000 messages in my inbox. I would like to clean out my inbox and delete some of these messages. Is this okay? Is email subject to the Records Retention Schedule?
Email may be subject to the Records Retention Schedule. The retention of a document (or message) depends on the content of the document – not whether it is in paper or electronic form. Unless you are receiving business related email from outside the university, you can most likely delete the vast majority of the messages you receive. Internal memos, announcements and informational items that you receive can be deleted as soon as they have served their information purpose to you. If you author documents or receive business email from outside customers or business partners, you may have an obligation to retain certain messages. For information, access the Guidelines for Electronic Records Management or contact the university’s Records Manager at (713) 500-8508 or (713) 500-8123.
The disclosure and nondisclosure of all documents, records, data and other information in the possession or control of the university is dictated by the requirements of the Texas Public Information Act. The university is required by law to release certain information. Additionally, the university is required by law to maintain the confidentiality of some information. If you receive a request for information or records from an external (non-university) person or entity, and the request is not authorized by an existing procedure or practice, you should immediately forward the request to the Office of Legal Affairs. For more information, consult HOOP Policy 132 Handling Requests for Public Information or call the Office of Legal Affairs at (713) 500-3268.
I received a phone call from a woman asking if I would send her copies of all email and other correspondence our office had sent to state leaders regarding tuition and fees. Should I make the copies and send them to her?
No. This is considered a public information request. Individuals verbally contacting you should be advised to submit their request in writing as specified on the university’s Open Records web page. For information, contact the Office of Legal Affairs at (713) 500-3268 or consult HOOP Policy 132 Handling Requests for Public Information.
Some of the mission activities of the university may involve the use of potentially hazardous agents. It is the intent of the university to create and maintain a safe and secure work environment and to be prepared to handle emergency and disaster conditions. It is the responsibility of each employee, trainee, contractor and visitor working with hazardous materials to ensure that his or her work environment is safe and that proper procedures are followed for the handling and disposal of potentially hazardous materials.
Each employee and trainee should immediately alert his or her supervisor or instructor and Environmental Health and Safety of:
- any injury or
- any situation presenting a danger of injury so that timely corrective action may be taken.
Environmental Health and Safety may be reached at (713) 500-8100.
For more specific information on health and safety and protection of the environment, consult the HOOP Policies on Safety and Health.
I am not sure how to dispose of the chemicals in my lab. Whom should I contact?
You should contact Environmental Health and Safety at (713) 500-8100.
I was accidentally stuck by a needle at work. Whom should I contact?
For student or resident injuries contact UT Student Health Clinic at (713) 500-5171 or for student or resident needle sticks that occur after hours contact the 24 hour pager (713) 951-8013. For employee injuries contact UT Health Services at (713) 500-3267 or for employee needle sticks that occur after hours contact the 24 hour pager at 1-800- 770-9206.
The policy of the university is to prohibit the unlawful purchase, manufacture, distribution, possession, selling, storing, or use of a controlled substance, in or on premises or property owned or controlled by the university. A controlled substance is a chemical agent that can be misused or abused. An employee or trainee who violates this policy is subject to disciplinary action, up to and including termination or dismissal. At the discretion of the university, an employee may be referred to an Employee Assistance Program and/or may be required to participate in and satisfactorily complete an approved rehabilitation program. A student may be referred to Student Health and Counseling Services. For more information, consult HOOP Policy 173 Substance Abuse in the Workplace.
Any employee who is convicted of a drug-related offense is required to notify his or her immediate supervisor within five days of the conviction. Supervisors who receive such notice must immediately inform the Office of Human Resources. For more information, consult HOOP Policy 173 Substance Abuse in the Workplace.
Possession of weapons on university property is strictly prohibited and is considered a violation of the Violence Free Workplace Policy, except as permitted by state law. For more information, consult HOOP Policy 39 Campus and Workplace Violence Prevention and HOOP 222, Concealed Handguns on Campus.
I believe that I saw one of my coworkers using illegal drugs at the workplace. What should I do?
You should report the suspected incident to your supervisor immediately and inform The University of Texas Police - Houston by calling 911.
One of my coworkers threatened to harm me physically. What should I do?
If you feel that the threat is one of imminent bodily harm, you should seek protective cover and call 911 immediately. Once the situation is safe, you must report the incident to your supervisor. If your supervisor is unavailable, you should report the incident as provided in HOOP Policy 39 Campus and Workplace Violence Prevention.
The use or possession of alcohol while at work, on university business, participating in university-related activities or while in vehicles used for university business is prohibited. Use of alcohol while not at work, on university business or participating in university-related activities that adversely affects job performance or that may adversely affect the safety of other university community members is prohibited. Any member of the university community who violates this prohibition may be subject to disciplinary action. For more information, consult HOOP Policy 173 Substance Abuse in the Workplace and HOOP 9, Alcoholic Beverages.
While the university discourages serving alcoholic beverages at most university events, alcoholic beverages may be served at selected events sponsored by the university or UT System. The arrangements to serve alcohol must be requested and approved in advance of the event. For more information, consult HOOP Policy 9 Alcoholic Beverages.
The university is committed to a tobacco-free environment for all members of the university community and for all other individuals who enter its leased or owned property. The use of tobacco is not permitted on the premises or grounds of the university. Failure to comply with this policy may result in disciplinary action, up to and including dismissal or termination. For more information, consult HOOP Policy 10 Tobacco-Free Workplace.
The Office of Public Affairs acts as the official spokesperson for the university. If a member of the media contacts you regarding university business, direct them to the Media Relations Hotline at (713) 500–3030.
Employees who are contacted directly by journalists must refer them immediately to the media hotline and/or contact the media hotline themselves. A Media Relations staff member will coordinate communications with external media and is authorized to serve as the official university spokesperson, if needed.
For more information, consult HOOP Policy 5 Communications with the Media.
A reporter stopped me on campus to ask me what I think about the cost of some of the construction projects on campus. Is it okay to answer the reporter’s questions?
You should ask the reporter to contact the Media Relations Hotline at (713) 500-3030. Media Relations staff members in the Office of Public Affairs can schedule interviews for the reporter and have the authority to speak on behalf of the university.
The university is committed to cooperating with government or other investigations of the university and its employees. However, it is essential that the legal rights of the university and its employees are protected. If you are contacted by a governmental agency or if you receive a subpoena, inquiry or other legal document from any governmental agency regarding university business, you should immediately contact the Office of Legal Affairs at (713) 500-3268. If you are contacted at your home, you may politely ask the agent or the investigator to contact you at your office as you are not required to speak to the agent at your home. You should also immediately contact the Office of Legal Affairs to notify them of the contact. For more information, consult HOOP Policy 147 Handling Legal Processes.
Two agents from the Department of Health and Human Services Office of Inspector General are in my office and are asking me to pull some files from our department for them, so that they can examine them. What should I do?
You should politely direct the agents to the Office of Legal Affairs at (713) 500-3268. Legal Affairs can ensure that the appropriate information is given to the agents and that the legal rights of the university and its employees and trainees are protected.
Updated 01/06; 08/07; 03/08; 03/09; 06/11; 6/15