Standards of Conduct Guide - A Guide to Excellence Through Integrity
Table of Contents
The UTHealth Institutional Compliance Program
- Institutional Compliance Program
- Faculty & Staff Member Responsibilities
- Management Responsibilities
- Addressing Ethical & Compliance Concerns
Preventing, Detecting and Reporting Fraud and Abuse and Billing Compliance
- Fraud and Abuse
- Federal False Claims Act and Remedies
- State False Claims Act and Remedies
- Billing Compliance
Ethical Standards & State Ethics Laws
- Ethical Standards
- Conflicts of Interest
- Gifts, Gratuities, & Items of Value
- Outside Employment, Board Service or Compensation
- Personal Investments
- Research Integrity
Workplace Conduct & Practices
- Equal Employment Opportunities
- Sexual Harassment & Sexual Misconduct
- Overtime Compensation
- Time & Leave Records
- Family or Personal Medical Needs
Use of UTHealth and State of Texas Resources
- Political Activities, Political Contributions
- Contracts and Agreements
- Purchases of Items, Goods or Services
- Computer Software
- Computer Information Security
Intellectual Property and Copyright
Records and Information
Health and Safety
- Workplace Health & Safety and Protection of the Environment
- Drug and Violence Free Workplace
- Smoke-Free Environment
Contacts with External Entities
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. In doing so, the university must maintain ethical, professional and legal standards to serve as the basis for our work. These standards are outlined in the university’s Standards of Conduct. The most critical element, however, in maintaining the success of these standards is you. Every university employee has a responsibility for maintaining our Standards of Conduct. It is important that you 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. Parsons, J.D.
Assistant Vice President & Chief Compliance Officer
The University of Texas Health Science Center at Houston
Mission and Vision
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.
Ethical conduct and following the policies, laws and regulations which apply to the university is the responsibility of each faculty and staff member. Each of us must be aware of the legal and ethical standards which apply to our job responsibilities. We must perform our duties and responsibilities in accordance with the provisions of federal and state laws, regulations and policies; the Rules and Regulations of the Board of Regents of the U.T. System; and the policies of The University of Texas Health Science Center at Houston. These responsibilities are outlined in the university’s General Standards of Conduct Policy in the university’s Handbook of Operating Procedures.
This booklet, A Guide to Excellence Through Integrity, is The University of Texas Health Science Center at Houston’s Standards of Conduct Guide. The Guide provides a summary of the responsibilities and standards of ethics and conduct that apply to all faculty and staff. 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 http://www.uthouston.edu/hoop/index.htm. Faculty and staff members may also seek guidance on specific ethical or compliance issues by contacting the Office of Institutional Compliance at (713) 500-3294.
Institutional Compliance Program
The purpose of the Institutional Compliance Program is to pro-actively promote compliance with all applicable legal and regulatory requirements. The compliance program strives to foster and help ensure ethical conduct and provide education, training and guidance to all faculty and staff members. These goals are accomplished through regular high risk identification, training and monitoring of the effectiveness of compliance activity. The goals, purpose and elements of the Institutional Compliance Program are contained in the university’s Institutional Compliance Plan. 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 Presidents for Research and Academic Affairs; and, the Medical School Executive Vice Dean for Clinical Affairs.
Faculty and Staff Member Responsibilities
Compliance is both an institutional and an individual commitment at The University of Texas Health Science Center at Houston. Each individual commits to:
- maintaining a working knowledge of the laws, regulations, policies, rules and procedures which apply to your individual job responsibilities;
- complying with the laws, policies and procedures which apply to your individual job responsibilities;
- upholding the highest legal and ethical standards in fulfilling your job duties 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 ensure and verify that all employees attend appropriate compliance training at the university.
It is the individual responsibility of each faculty and staff member 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 of Texas Health Science Center at Houston’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 must report the action using any of the following steps:
- 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 e-mail or by meeting.
- Make a report in an exit interview statement given upon the conclusion of employment at UTHealth.
- Make a report through the designated UTHealth Compliance E-mail address: email@example.com.
- Make a report through the designated “Web Reporting” website: https://www.tnwgrc.com/WebReport/default.asp?.
Faculty and staff are encouraged to directly contact the Chief Compliance Officer at (713) 500-3294 to discuss compliance questions or concerns.
As stated above, The University of Texas Health Science Center at Houston has established a Compliance Hotline and Web Reporting. The Compliance Hotline is intended to supplement regular communication channels. Faculty and staff 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 the normal administrative 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.
UTHealth 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. Persons making disclosures with reckless disregard for the truth or in willful ignorance of the facts may be subjected to disciplinary action. 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 anonymously and confidentially. You do not have to give your name when you call the Hotline or report on the website. Additionally, both university policy and state law protect you from retaliation.
What are some examples of retaliation?
Retaliation is adverse action taken against an employee who has reported suspected misconduct when business related reasons do not exist for the action. Some examples of retaliation are listed below.
- 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 University of Texas System Fraud Policy, UT System Policy 118, specifies our 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 of Texas Health Science Center at Houston 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.
Examples of a False Claim:
- Billing for procedures not performed
- Falsifying information in a medical record
- Duplicate Billing
- Falsifying claim forms to receive overpayment for services provided
Federal False Claims Act Remedies:
- A federal false claims action may be brought by the U.S. Department of Justice Civil Division, the United States Attorney.
- 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 $5,000 and $10,000 per false claim, plus three times the amount of damages incurred by the government.
- A statute of limitations says how much time 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 Whistleblower Protections:
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 False Claims Act:
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 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.
Texas Whistleblower Protections:
The Texas False Claims Act also has a whistleblower provision which 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.
It is the individual responsibility of all individuals who are employed by, affiliated with, under a contract or agreement, or otherwise under the control of the University, to report any activity that appears to be in violation of any state or federal law, including the federal or state false claims act, through the normal administrative channels or any other reporting paths described in these guidelines.
It is not required that possible false claims act violation be reported to the University first. Reports may be made directly to the federal Department of Justice or the U.S. Health and Human Services Office of Inspector General Hotline telephone number, 1–800–447–8477 (1–800–HHS–TIPS).
UTHealth 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 UTHealth shall adhere to applicable federal and state laws and regulations, The University of Texas System Board of Regents’ Rules and Regulations, and UTHealth policies. The institution 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. UTHealth shall collect only those amounts to which the institution is entitled and refund amounts billed and/or collected in error. Employees and medical staff members will receive disciplinary action for failure to abide by the applicable federal and state laws and regulations, The University of Texas System Board of Regents’ Rules and Regulations and UTHealth policies.
Examples of 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. If you do not feel comfortable discussing the issue with your supervisor, you may contact the Office of Institutional Compliance at (713) 500-3294. You may also contact the Compliance Hotline at 1-888-472-9868.
The State of Texas and the Board of Regents of The University of Texas System have defined certain ethical standards that apply to faculty and staff members of the UT System. For further information, consult the U.T. 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 directly 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 hard 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 UTHealth 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 between the interests of UTHealth and university employees’ private interests and may prevent university employees from making decisions that are in the best interest of UTHealth. Even if those outside interests do not actually impair university employees’ ability to act in the best interest of UTHealth, it may appear to the public that independence of judgment has been affected. For more information, consult HOOP Policy 20 Conflicts of Interest and Outside Activities.
I am a department head and have been working with a health science center 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 health science center business for this vendor. Tex. Penal Code §36.08.
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 faculty or staff benefit financially from books or other writings that were purchased with health science center funds?
No. Royalties from books, scholarly works or other writings that are purchased with health science center funds may not be retained by faculty or staff. Faculty and staff must account for, and remit to the health science center, 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?
It is okay to 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 discipline, including termination.
Under the criminal standard, criminal penalties may apply to persons who make recommendations or decisions about UTHealth financial transactions. University employees who make recommendations or decisions about UTHealth 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 as long as the gift is not given in exchange for official action (it is never lawful to accept a gift 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 faculty or staff member accepts them as a “guest,” which means the donor must be present.
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 UTHealth 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.
Outside Employment, Board Service or Compensation
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 UTHealth. External consulting or outside employment that interferes with those duties and responsibilities should not be accepted. At the same time, UTHealth recognizes the benefits of employees’ participation in activities of a consultative or advisory capacity with governmental agencies, private industry, or other institutions 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 to serve its stakeholders, the University believes these activities improve the performance of an employee by virtue of his or her continuing contact with issues/problems in the nonacademic world and serve to promote the University. In general, faculty members may devote up to thirty (30) working days in any fiscal year to outside consultative or advisory activities with governmental agencies, private industry or other institutions, whether compensated or not, as long as these activities are not in conflict with the proper discharge of their duties and responsibilities in the public interest. This thirty (30) working day time threshold does not apply to or affect service to activities conducted for university-related Governmental, University or Non-Profit Boards, Study Sections, Committees, and Projects or required attendance for service in the United States armed forces (See HOOP Policy 41 Military Leave). Any outside employment, including self-employment, consulting or employment by another state agency, must first be approved by the faculty or staff member’s immediate supervisor. All requests must be approved in writing in advance. Individual immediate supervisors have the right to limit a staff or faculty member’s outside activities if they conflict with the ability of the faculty or staff member to perform the obligations of his or her University responsibilities.
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, faculty or staff members 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 as long as the services are more than merely perfunctory or superficial. Also, 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 position at the university and because of my research work. I have been offered a small fee to give the speech along with reimbursement for my food, transportation and lodging. Can I accept the fee? What about the food, transportation and lodging?
You cannot accept the fee 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 direct or indirect financial interest in a business that conflicts with UTHealth 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 supervisor or consult with the UTHealth Office of Institutional Compliance.
If employees have an interest in a business they think might constitute a conflict of interest, they should disclose that interest to their supervisor. 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 UTHealth, 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 then you must report your ownership to your supervisor.
Self-Dealing/Transactions with Employees
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 UTHealth 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 of Texas Health Science Center at Houston 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. Faculty, trainees and staff 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, conducting or reporting research. Honest errors or honest differences in interpretations or judgments of data do not violate the university’s Honesty in Research policy.
How do I report scientific misconduct?
You should report any allegations of dishonesty, misconduct, or fraud in research to the appropriate department chair or dean. If the allegations involve a department chair or dean, they should be reported to the Executive Vice President for Research. For more information, consult HOOP Policy 202 Honesty in Research.
The University of Texas Health Science Center at Houston respects the privacy of every patient. Patients expect the information they give to their health care providers will 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 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/. Contact the Privacy Office at (713) 500-3391 for specific questions.
Faculty or staff members who have patient questions related to research can also consult the CPHS Researchers Guide to HIPAA.
Sensitive information about health science center students, employees, strategies, and operations must be protected. Employees who handle sensitive information shall follow all administrative, technical, and physical safeguards implemented by the health science center for the protection of sensitive information.
An employee may use or request sensitive information to perform their job. However, that information must not be shared with others, inside or outside of the health science center, 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 includes:
- personnel data,
- social security numbers,
- student information,
- patient information,
- research data,
- financial data,
- strategic plans,
- marketing strategies,
- employee lists and data,
- supplier and subcontractor information,
- proprietary computer software.
Email Transmission of Sensitive Information
UTHealth faculty members, students, staff or contractors are required to obtain a digital ID if they transmit or receive confidential information across the internal UTHealth network or public network, must digitally sign electronic documents, and/or require access to restricted resources requiring strong authentication. For more information, consult HOOP Policy 179 Responsibilities for the Use of Digital IDs.
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 may not request disclosure of a social security number if it is not necessary and relevant to the purposes of the health science center 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.
For more information, consult UT System Policy 165, Information Resources Use and Security Policy and HOOP Policy 175 Responsibility for the use of Information Resources.
While typing 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 on my office door 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, as long as the student identification number cannot be identified with the student associated with that number.
The University of Texas Health Science Center at Houston is committed to providing a safe and healthy workplace environment. Health science center staff are encouraged to treat each other in a fair and respectful manner. The University of Texas Health Science Center at Houston, in accordance with applicable federal and state 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 hiring or status, it is the policy of The University of Texas Health Science Center at Houston to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, sexual orientation, disability or veteran status. Further, it is the policy of The University of Texas Health Science Center at Houston to provide a work environment free from verbal, physical, and/or visual forms of discrimination or harassment. For further information, consult HOOP Policy 183 Equal Opportunity, Discrimination and Harassment.
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?
Human Resources – Equal Opportunity manages all allegations of discrimination. If you feel you have been discriminated against, contact the Human Resources – Equal Opportunity at (713) 500-3079.
The University of Texas Health Science Center at Houston is committed to providing a working environment free from inappropriate conduct of a sexual nature. Faculty or staff members who engage in such conduct will be subject to disciplinary action, up to and including termination. Should a situation of sexual harassment or misconduct arise, immediately contact the Human Resources – Equal Opportunity division at (713) 500-3079. Resources are available to conduct a thorough investigation that protects the rights of all involved parties. For more information, faculty and staff members should consult HOOP Policy 183 Equal Opportunity, Discrimination and Harassment.
What are examples of behavior that could be considered sexual misconduct or harassment?
Examples of behavior that could be considered sexual misconduct or harassment include but are 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 of Texas Health Science Center at Houston strives to comply with all provisions of the Fair Labor Standards Act (FLSA). The FLSA is a federal law which requires payment to covered 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 health science center are classified employees. Employees must specifically obtain prior approval for overtime and compensatory time before it is worked. 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 you are classified as an employee who is covered by the FLSA and the overtime was approved by your supervisor in advance. For more information, contact the Compensation Manager in the Office of Human Resources at (713) 500-3130.
The University of Texas Health Science Center at Houston requires all faculty and staff members to submit a record reflecting their hours worked and hours absent from work. The health science center maintains an electronic Time Management System which records the hours worked and hours absent of all faculty and staff members. Faculty and staff members should submit their time records in the Time Management System in accordance with the schedule outlined in HOOP Policy 24 Time and Attendance Reporting. For specific questions regarding the Time Management System, consult the designated Timekeeper in your department or contact Payroll.
The University of Texas Health Science Center at Houston acknowledges that faculty and staff members may need time to attend to personal or family medical needs for serious health conditions or the birth, adoption, or placement of a baby. HOOP Policy 106 Family and Medical Leave, details how a faculty or staff member may obtain leave in these circumstances. Faculty and staff members should also consult with an Employee Relations Advisor in the Office of Human Resources. The Employee Relations Advisors can be reached 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 of Texas Health Science Center at Houston.
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.
Each faculty and staff member is responsible for protecting and preserving The University of Texas Health Science Center at Houston property, equipment and supplies. The conservation of state resources is a responsibility that university faculty and staff members, 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 e-mail, is permitted under the following circumstances:
- The use does not result in a cost to The University of Texas Health Science Center at Houston.
- 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 okay. 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 Policy 176 Use of University Telecommunications - Telecommunications.
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 okay so long as the use conforms to the permissible use and prohibited use sections of HOOP Policy 180 Email and Internet Usage. 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 with a display informing me that I was a attempting to visit a potentially inappropriate site popped up. What should I do?
The block screen is triggered when sites which potentially contain material deemed inappropriate by executive management 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 health science center username and password at the time of access. If you do not know your health science center username and password, you should contact the Information Services Helpdesk at (713) 500-4848.
Faculty and staff members may participate in political activities if:
- the political activity is not during work hours;
- the political activity does not interfere with job duties and responsibilities;
- the faculty or staff member does not force other university community members to participate in the political activity;
- the faculty or staff member does not use the equipment, supplies or services of the health science center;
- the political activity does not involve the university in partisan politics; and,
- the political activity is not illegal.
For more information, consult HOOP Policy 38 Political Activity.
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.
Political contributions from any source of The University of Texas Health Science Center at Houston funds are prohibited.
Only individuals expressly authorized in writing by The University of Texas Health Science Center at Houston President may enter into contracts or agreements, either oral or written, on behalf of the health science center. No faculty or staff member may sign a contract on behalf of the health science center unless expressly authorized to do so in writing by the health science center President. For more information, consult The University of Texas Board of Regents' Rules and Regulations for Procurement of Certain Goods and Services and HOOP Policy 124 Authority to Execute Contracts and Make Purchases.
A sales representative has asked me to immediately sign a “purchase agreement” because the product price will increase tomorrow. Can I do so?
No, not 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.
Faculty and staff members may not use health science center 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/bor/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 of Texas Health Science Center at Houston 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 UTHealth to do UTHealth work on a personal home computer is not permitted, unless expressly authorized in the license agreement. If you have questions, you can speak with your supervisor, the Local Area Network Manager, or the Office of Information Services at (713) 500-2221. You may also consult HOOP Policy 198 Software Copyright Compliance.
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. Talk to your supervisor, your Local Area Network Manager, or the Office of Information Services before you copy the software to make sure that it is okay.
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. It is a violation of the Texas Penal Code to disclose computer passwords. Penalties range from a Class B misdemeanor to a felony depending on the related monetary damage. 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 e-mail 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. Talk to your supervisor, your Local Area Network Manager or the Office of Information Services if you need further information or assistance.
Intellectual Property & Copyright
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 “know how” to others.
The University of Texas Health Science Center at Houston’s Office of Technology Management provides a resource to health science center faculty, staff and student inventors to explore the possibilities of their creations, and facilitate technology transfer activities that bring new discoveries to the people of Texas and generate financial benefits for the health science center and its family of creators.
Intellectual property that is related to an individual’s employment responsibility, or has resulted either from activities performed by an individual while employed by The University of Texas, or supported by state funds, or while using The University of Texas facilities, belongs to The University of Texas. The University of Texas System Intellectual Property Policy applies to all health science center employees, including candidates for masters and doctoral degrees, as well as pre-doctoral and postdoctoral fellows.
Intellectual property resulting from research supported by a grant to The University of Texas Health Science Center at Houston or The University of Texas System belongs to The University of Texas Health Science Center at Houston or The University of Texas System.
Whenever intellectual property is created by a health science center faculty or staff member, the faculty or staff member must disclose the intellectual property to the health science center’s Intellectual Property Committee. Disclosure of an invention or discovery by publication or presentation to the public or industry before disclosure to the health science center’s Intellectual Property Committee is a violation of The University of Texas System Intellectual Property Policy.
For more information on how to disclose an invention or discovery to the health science center’s Intellectual Property Committee, please contact the Office of Technology management at (713) 500-3369 or visit their web page at http://www.uth.tmc.edu/otm/. The Office of Technology Management can also provide you with information on patent protection for an invention or discovery and the health science center’s royalty distribution policy.
I submitted a manuscript for publication in a scientific journal on a development that may be patentable. What is the next step?
An Invention Disclosure Form should be submitted to the health science center’s Intellectual Property Committee through the Office of Technology Management 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 the Office of Technology Management at (713) 500-3369 or visit their web page at http://www.uth.tmc.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. In general, 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 out of a scientific journal I subscribe to, to distribute to my students for discussion in our next class. Is that okay?
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. The Copyright Guidelines may be found in the HOOP. Faculty members are encouraged to review the Copyright Guidelines and become familiar with them. Should you require further assistance, contact the Office of Technology Management at (713) 500-3369.
Faculty and staff members of the university are responsible for maintaining the integrity and accuracy of health science center business documents and records for which they are responsible. Faculty and staff members 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 what was changed.
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 faculty or staff member 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) 500-3100. 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 some 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) 500-3100.
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. If you have questions, you can access the Guidelines for Electronic Records Management. If you have additional questions, contact the university’s Records Manager at (713) 500-3100.
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 also 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 & Institutional Compliance. 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 to the Chief Operating & Financial Officer. If you have any questions or concerns, contact the Office of Legal Affairs at (713) 500-3268 or consult HOOP Policy 132 Handling for Requests for Public Information.
Some of the mission activities of The University of Texas Health Science Center at Houston may involve the use of potentially hazardous agents. It is the intent of the university to both 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 faculty and staff member to ensure that their work environment is safe, healthy and that proper procedures are followed for the handling and disposal of potentially hazardous materials.
Each faculty and staff member should immediately alert their supervisor and Environmental Health & Safety of:
- any workplace injury or
- any situation presenting a danger of injury so that timely corrective action may be taken.
Environmental Health & Safety may be reached at (713) 500-8100.
For more specific information on Workplace Health & 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 & Safety at (713) 500-8100.
I was accidentally stuck by a needle at work. Whom should I contact?
For student/employee injuries contact UT Medical Health Services at (713) 500-3267
or for student 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 (713) 500-3267 or 1-800- 770-9206.
It is the policy of The University of Texas Health Science Center at Houston 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. A faculty or staff member who violates this policy is subject to disciplinary action, up to and including termination. At the discretion of the university, the faculty or staff member may be referred to an Employee Assistance Program and/or may be required to participate in and satisfactorily complete an approved rehabilitation program. For more information, consult HOOP Policy 173 Substance Abuse in the Workplace.
Any faculty or staff member who is convicted of a drug-related offense occurring in the workplace 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 health science center property is strictly prohibited and is considered a violation of the Violence Free Workplace Policy. For more information, consult HOOP Policy 39 Violence Free Workplace.
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 UT Police 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 to the STOP Line at (713) 792-7867. For more information, consult HOOP Policy 39 Violence Free Workplace.
The use or possession of alcohol while at work or while in vehicles used for university business is prohibited. Use of alcohol while not at work which 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.
While the university discourages serving alcoholic beverages at most university events, alcoholic beverages may be served at selected events sponsored by the health science center or The University of Texas 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 of Texas Health Science Center at Houston is committed to a completely smoke-free environment for all members of the university community and for all other individuals who enter its leased or owned property. Smoking 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 expulsion or termination. For more information, consult HOOP Policy 10 Smoking.
Contacts with External Entities
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 Office of Public Affairs at (713) 500–3030.
If a faculty member is contacted by the media regarding his or her research, publications, teaching, or clinical work, he or she is encouraged to promote their work and the university. However, faculty members are encouraged to direct the media to the Office of Public Affairs so that Public Affairs can discourage nuisance calls and inform the media about other university activities.
For more information, consult HOOP Policy 5 Handling 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 Office of Public Affairs at (713) 500-3030. Public Affairs can schedule interviews for the reporter and has the authority to speak on behalf of the university.
The health science center is committed to cooperating with government or other investigations of the university and its faculty or staff members. However, it is essential that the legal rights of the health science center and its faculty and staff members 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 & 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 faculty and staff members are protected.
Updated 01/06; 08/07; 03/08; 03/09; 06/11