Click here to enter Policy # and Title

Effective Date: [Click here to enter the date the policy was first put into effect]

Revised Date: [Click here to enter the date the policy was last revised

Reviewed Date: [Click here to enter the last date the policy was reviewed without revision

Next Review Date: [Click here to enter the date the policy will next be reviewed]

Administrative Responsibility: [Click here to enter the POSITION, not name of the individual, responsible for interpreting and revising the policy]

1. PURPOSE
   1. [Click here to enter a statement describing the purpose of this policy.]
2. SCOPE
   1. [Click here to replace this text with a statement indicating the employee groups that are impacted by this policy.]
3. DEFINITIONS [Below, list terms and definitions related to this policy. To delete this text, click it and then press Delete.]
   1. [Click here to enter Term and Definition or "N/A" if not applicable]
   2. [Click here to enter Term and Definition or "N/A" if not applicable]
   3. [Click here to enter Term and Definition or "N/A" if not applicable]
4. POLICY [Below, list steps by which the policy's actions can be accomplished. To delete this text, click it and then press Delete.]
   1. [Click here to enter policy]
   2. [Click here to enter policy]
   3. [Click here to enter policy]

5. PROCEDURE [Below, provide continuing guidelines to management for making daily decisions. To delete this text, click it and then press Delete.]
   1. [Click here to enter procedure guideline]
   2. [Click here to enter procedure guideline]
   3. [Click here to enter procedure guideline]

6. REFERENCES [Below, list regulatory or other references pertinent to this policy. To delete this text, click it and then press Delete.]
   1. [Click here to enter reference or "N/A" if not applicable]
   2. [Click here to enter reference or "N/A" if not applicable]
   3. [Click here to enter reference or "N/A" if not applicable]
7. APPENDICES [Below, list if applicable, documents attached to this policy. To delete this text, click it and then press Delete.]
   1. [Click here to enter Appendix name and title or "N/A" if not applicable]
8. PREVIOUS REVISION DATES [Below, list all previous revision dates. To delete this text, click it and then press Delete.]

[Click here to enter all previous revision dates or "N/A" if not applicable]

9. SUPERSEDES POLICY [Below, list any policy that this policy takes the place of. To delete this text, click it and then press Delete]
   1. [Click here to enter Policy # and title or "N/A" if not applicable]
10. APPROVALS

Policy Committee:  [Click here to enter date approved.]

[Click here to enter name of VP approving this policy.]                     [Click here to enter date.]

[Click here to enter title of approver]                                                     DATE