Create or Update Policies

Effective Date:

August 25, 2015


Policy and Procedure Administration


Nadia Sidarous

Basis for Procedure

When a new Policy or an update to an existing Policy is needed due to a new or updated regulation or law, standard review (per RF Policy review cycle), function level internal controls review, or other special circumstances it is important that the Policy is reviewed and approved by the appropriate stakeholders.

Procedure Summary

This Procedure outlines the necessary steps to publish a new or updated Policy from draft to final approval.

Procedure Steps


Role or Responsibility

References or Tips

Conduct an Environmental Scan and determine what changes need to be made or if new policy is required.

Policy Owner or Designee


Contact the Office of Compliance Services to confirm the type of document being created/updated (Policy, Procedure or Guideline), and determine next steps.

Policy Owner or Designee


Formulate the draft using the, Policy Template, in Microsoft Word.

Policy Owner or Designee

To enhance usability of these on the web, the word "policy", if used, must be at the end of the official title.

Make sure to follow RF Corporate Style Guide.

If updating a current Policy, be sure to update it using the new template.

Work with campus colleagues (either established focus groups or specific staff based on policy content), SUNY System Administration as needed, and RF Counsel for draft.

Policy Owner or Designee

RF counsel is responsible for consulting with SUNY’s Compliance Administrator to obtain SUNY counsel input as appropriate.

Develop a communication and training plan. Consult with External Relations, Training Unit or Office of Compliance Services.

Policy Owner or Designee


Submit draft to ECT for review.

Office of Compliance Services


Begin filling out the form, New or Updated Policy. At each of the following review stages, this form must accompany the Policy draft.

Policy Owner or Designee


Submit to the Management Council for review and recommendation to the Leadership Team.

Policy Owner or Designee

It is recommended that either a Management Council member knowledgeable about the Policy or the Leadership Team sponsor be present at this meeting.

Submit to RF Leadership Team who will advise the President to approve or reject policy.

Policy Owner or Designee

Please Note: Some policies may require Board approval.

Ensure that RF counsel has reviewed and signed off on the final draft prior to presentation to RF President.

Policy Owner or Designee


If approved and signed by the President, submit the final draft to, and request that it be posted on RF website. Include the completed form New or Updated Policy

Policy Owner or Designee

If rejected, proceed to make recommended changes to document, and resubmit to Leadership Team.

If updating an existing Policy, archive the former version.

Office of Compliance Services


Enter all changes into Author IT, post Policy on RF website and notify the Policy owner

Office of Compliance Services


Once the notification has been received, update the form, New or Updated Policy

Office of Compliance Services


Communicate as necessary according to communication plan.

Policy Owner or Designee



Policy: Governing rule or principle that requires or prohibits conduct.

Procedures: Required steps to implement or comply with a related policy.

Guidelines: Optional steps outlining suggested ways to perform a function or adhere to a policy or procedure.

ECT: Enterprise Compliance Team, composed of cross functional members of campus and central office.

Related Information

Establishing Policies and Procedures

Create or Update Procedures and Guidelines


New or Updated Policy

Policy Template

Change History


Summary of Change


Rearranged the procedure to make document more efficient and easy to follow.


New Document



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