Create or Update Procedures and Guidelines

Effective Date:

August 25, 2015


Policy and Procedure Administration


Nadia Sidarous

Basis for Procedure

When a new Procedure/Guideline or an update to an existing Procedure/Guideline is needed, due to a new or updated regulation or law, function level internal controls review or other special circumstances it is important that the Procedure/Guideline is reviewed by the appropriate RF staff prior to publishing.

Procedure Summary

This procedure outlines the necessary steps to publish a new or updated Procedure/Guideline 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 Procedure/Guideline is required.



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

Procedure Owner or Designee


Formulate draft using the, Procedure Template or Guideline Template in Microsoft Word.

Procedure Owner or Designee

To enhance usability of these on the web, the word "procedure/guideline", if used, must be at the end of the official title. Make sure to follow RF Corporate Style Guide.

If updating current Procedure or Guideline, be sure to update using the new template.

Work with campus colleagues (either established focus groups or specific staff based on Procedure/Guideline content) and RF Counsel for final draft.

Procedure 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

Procedure Owner or Designee


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

Procedure Owner or Designee


Submit the final draft to and request that it be posted on RF website. Include the completed form New or Updated Procedure/Guideline

Procedure Owner or Designee


If updating an existing Procedure or Guideline, archive the former version.

Office of Compliance Services


Enter all changes into Author IT, post policy on RF website, and notify the Procedure/Guideline owner.

Office of Compliance Services


Once notification has been received, update the form, New or Updated Procedure/Guideline

Office of Compliance Services


Communicate as necessary according to communication plan.

Procedure 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.

Related Information

Establishing Policies and Procedures

Create or Update Policies


New or Updated Procedure/Guideline

Procedure Template

Guideline Template

Change History


Summary of Change


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


New Document



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