compliance and ethics program structure · compliance and ethics program structure ... the cep will...
TRANSCRIPT
NACUA Fall CLE Workshop 2009 (Washington, DC)
Compliance and Ethics Program Structure
Adopted by ECC June 18, 2008 Last updated August 31, 2009
NACUA Fall CLE Workshop 2009 (Washington, DC)
The University of Texas at Austin
COMPLIANCE AND ETHICS PROGRAM
CHARTER
Purpose
The purpose of the University of Texas at Austin (“University”) Compliance and Ethics Program (“CEP”) is to promote and support a working environment which reflects the University’s commitment to maintaining the highest level of integrity and ethical standards in the conduct of its operations. Towards this end, the CEP will include programs and practices designed to nurture and preserve the University’s culture of respect and honesty while building compliance and ethics consciousness into the daily activities of its faculty and staff.
Goal and Objectives
The CEP shall be designed and administered to help the University’s employees perform their duties as efficiently as possible while affirming the University’s commitment to the highest standards of ethics and integrity. The CEP shall be implemented as a risk based process that reasonably satisfies the requirements of the U.S. Sentencing Commission’s Guidelines for Organizations for an effective compliance and ethics program, and complies with all applicable laws, regulations and policies of The University of Texas System (“UT System”). In particular, the CEP shall include elements intended to achieve the following objectives:
a. promotion of an organizational culture that encourages all employees to conduct University business ethically and with a commitment to compliance with the law;
b. assurance that executive level personnel of the University are knowledgeable about the content and operation of the CEP and exercise reasonable oversight with respect to its implementation and effectiveness;
c. effective communication regarding the CEP to all levels of employees and to relevant vendors and other third parties;
d. establishment of clear compliance standards for all employees and consistent enforcement of these standards;
UT Austin CEP Charter, page 2 of 4
Adopted by ECC June 18, 2008 Last updated August 31, 2009
NACUA Fall CLE Workshop 2009 (Washington, DC)
e. maintenance of training programs appropriate for the proper education of employees with respect to compliance issues related to their job functions;
f. development and maintenance of a compliance and ethics risk assessment and management process that provides for
i. designation of the compliance and ethics risk areas of the University;
ii. completion of a risk assessment (to inventory compliance and ethics risks and to evaluate each inventoried risk for potential impact on the organization and probability of occurrence) in each risk area;
iii. based on these risk assessments, identification of the critical institutional compliance and ethics risks (“A Risks”);
iv. establishment of a “risk management process” that is fully responsive to the identified objectives for each A Risk (a risk management process evaluates current activities and identifies changes, if necessary, that will improve assurance of compliance, follows up to ensure that agreed upon changes are implemented, and then evaluates the results after implementation); and
v. designation of an individual to be held accountable for the implementation of an appropriate action plan to achieve compliance and ethics risk management improvement in the respective risk area;
g. maintenance of a process for continuously monitoring the compliance and ethics environment of the institution to identify new or changing compliance and ethics risks;
h. establishment of a mechanism for reporting suspected compliance and ethics violations that provides for anonymity and confidentiality to the extent allowed by applicable law;
i. maintenance of a process for investigating reports of suspected non-compliance, and effecting appropriate corrective, restorative and/or disciplinary actions;
j. maintenance of a process for the continued enhancement and improvement of the CEP and
k. prevention and detection of criminal activity and other misconduct and the recurrence thereof.
UT Austin CEP Charter, page 3 of 4
Adopted by ECC June 18, 2008 Last updated August 31, 2009
NACUA Fall CLE Workshop 2009 (Washington, DC)
Program Structure
The structural components of the CEP include the Executive Compliance Committee (“ECC”), University Compliance Services (“UCS”) (under the guidance of its Director ([“Director”]), the risk area Designated Responsible Party (“DRP”) and the Compliance Officers Group (“COG”). The major documentary components of the CEP include this CEP Charter, the ECC Charter and the formally adopted policies and practices of the University set out in the Handbook of Operating Procedures, including those set out in Part 4 of the Handbook of Operating Procedures entitled “Standards of Conduct”, and UT System policy (the “UT Policies”) and generally described in the Employee Compliance Guide (“Guide”). To the extent there is a conflict in the provisions of these documentary components, the provisions of the Policies shall prevail.
The ECC is composed of the President of the University, as chair, and those members of the University’s faculty and staff serving as provided for in the ECC Charter. The ECC shall be responsible for the oversight of the CEP and shall have the duties and responsibilities set out in the ECC Charter.
The UCS shall be responsible for the strategic design and implementation of the CEP as authorized and provided for by the ECC. In fulfilling this obligation, the UCS will provide advice and services in four primary areas: (1) training and general education help faculty and staff identify and understand relevant legal, regulatory and policy constraints, emphasizing the personal responsibility of all employees to eliminate misconduct and other wrongdoing and to conduct University business in an ethical and legal manner, (2) operational support – help faculty and staff having management responsibilities develop and implement practical strategies to avoid compliance and ethics failures using risk-based and other appropriate methodologies, (3) effort coordination – serve as a liaison between and among employees of the various University divisions having compliance responsibilities and executive management to better associate their CEP related activities, and (4) assurance – undertake those processes and actions well suited for verification and validation of the CEP’s effectiveness and otherwise provide assurance to the ECC that compliance and ethics risks are being managed and mitigated to acceptable levels. The UCS will conduct such other activity as reasonably calculated to achieve the goals and objectives of the CEP.
The Director shall be responsible for the daily administration of the UCS and shall serve as the University’s designated Institutional Compliance Officer for purposes of UT System policy UTS 119. The Director shall also serve as an ex-officio member of the ECC and as chair of the COG.
The COG shall be composed of (1) the Director, as chair, (2) a representative from the Office of Internal Audits, (3) a representative from the Office of the Controller, (3) a representative from the Office of the Vice President for Research, (4) a representative from the Office of Environmental Health and Safety, (5) a representative from the Office of the Vice President for
UT Austin CEP Charter, page 4 of 4
Adopted by ECC June 18, 2008 Last updated August 31, 2009
NACUA Fall CLE Workshop 2009 (Washington, DC)
Information Technology, (6) a representative from the department of Intercollegiate Athletics, and those faculty and staff having compliance related job responsibilities and duties who have been invited to join the COG by the Director. The COG will meet at least quarterly, and at other times as necessary, to discuss and advise the Director on non-fiscal policy and operational issues related to: CEP design, risk assessments, assurance and training activities, professional development and other issues pertinent to the compliance risk areas of the University.
The DRP is that individual designated by the ECC as being responsible for management of each A Risk specified in risk assessments of the University. Each DRP shall have the knowledge and authority necessary to manage that risk and shall cooperate with the UCS to develop a risk management process which includes training, monitoring and reporting plans for each A Risk. Even though the DRP may have delegated the actual management duties to a subordinate, the DRP shall continue to be responsible to the ECC for the performance of these obligations.
Program Standards
The CEP shall be designed recognizing that building and maintaining a culture of compliance, ethics and integrity are shared responsibilities and require individual commitments from all University faculty and staff. The standards by which University employees are expected to conduct their activities are set out in the Policies and generally described in the Guide. The Policies provide the framework within which all employees are expected to operate and apply to all University employees, including administration, faculty, fellows, residents, and students. Moreover, many of the Policies are applicable to University subcontractors, independent contractors, consultants and vendors. The Guide summarizes and makes citation to the Policies, applicable law and regulations, and the Rules and Regulations of the Board of Regents of the University of Texas System, known as Regents' Rules and Regulations. The Guide is designed to (1) communicate to all University employees an expectation and requirement of ethical conduct and compliance with all applicable laws, policies, rules, and regulations, (2) provide specific examples of conduct and behavior that are consistent with these expectations and (3) along with the Policies, serve as a reference for measurement of the CEP’s effectiveness. The Guide does not address all general compliance issues, nor does it deal with the many special compliance issues that are job specific. Instead, the Guide should be regarded as a set of guiding principles that apply to every University employee.
TH
E U
NIV
ER
SIT
Y O
F T
EX
AS
INST
ITU
TIO
NA
L C
OM
PL
IAN
CE
PR
OG
RA
M S
EL
F-A
SSE
SSM
EN
T
***
FIN
AL
DR
AFT
***
Ver
01/
23/0
8
The
Uni
vers
ity o
f Tex
as C
ompl
ianc
e Se
lf A
sses
smen
t Too
l
Pag
e 1
of 8
N
AC
UA
Fal
l CLE
Wor
ksho
p 20
09 (W
ashi
ngto
n, D
C)
Qu
esti
on
Yes
N
o D
ocu
men
tati
on, C
omm
ents
, Ob
serv
atio
ns
E
XE
CU
TIV
E C
OM
PL
IAN
CE
CO
MM
ITT
EE
:
1.
Doe
s the
Inst
itutio
n ha
ve a
n E
xecu
tive
Com
plian
ce
Com
mitt
ee in
plac
e?
Prov
ide
list o
f mem
bers
.
2.
Doe
s the
Exe
cutiv
e Co
mpl
iance
Com
mitt
ee h
ave
a ch
arte
r or
oth
er d
ocum
ent d
etail
ing
its d
uties
and
resp
onsib
ilitie
s?
If y
es, p
lease
pro
vide
a c
opy
of th
e ch
arte
r. If
not
, plea
se d
escr
ibe
the
Exe
cutiv
e Co
mpl
iance
Co
mm
ittee
’s ro
le, m
eetin
g fr
eque
ncy,
and
resp
onsib
ilitie
s.
3.
Has
the
Exe
cutiv
e Co
mpl
iance
Com
mitt
ee e
stab
lishe
d a
mec
hani
sm fo
r the
Com
plian
ce fu
nctio
n, if
a se
para
te
com
plian
ce fu
nctio
n ex
ists,
to re
port
its a
ctiv
ity to
the
Com
mitt
ee?
If y
es, p
lease
pro
vide
a d
escr
iptio
n of
the
stru
ctur
e or
or
gani
zatio
n.
4.
Has
the
Exe
cutiv
e Co
mpl
iance
Com
mitt
ee e
stab
lishe
d a
wor
king
gro
up /
com
mitt
ees/
subc
omm
ittee
s to
addr
ess e
ach
signi
fican
t com
plian
ce a
rea
at th
e co
mpo
nent
? D
oes t
he
resp
onsib
le pa
rty o
r the
ir re
pres
enta
tive
serv
e on
the
wor
king
gr
oup
or c
omm
ittee
? If
yes
, plea
se p
rovi
de c
omm
ittee
nam
es, c
hairs
, mem
bers
.
5.
Has
the
Exe
cutiv
e Co
mpl
iance
Com
mitt
ee e
stab
lishe
d a
mec
hani
sm to
mon
itor a
ctiv
ity in
eac
h “A
” lis
t, or
hig
h-ris
k ar
ea?
If y
es, p
lease
pro
vide
.
TH
E U
NIV
ER
SIT
Y O
F T
EX
AS
INST
ITU
TIO
NA
L C
OM
PL
IAN
CE
PR
OG
RA
M S
EL
F-A
SSE
SSM
EN
T
***
FIN
AL
DR
AFT
***
Ver
01/
23/0
8
The
Uni
vers
ity o
f Tex
as C
ompl
ianc
e Se
lf A
sses
smen
t Too
l
Pag
e 2
of 8
N
AC
UA
Fal
l CLE
Wor
ksho
p 20
09 (W
ashi
ngto
n, D
C)
Q
ues
tion
Y
es
No
Doc
um
enta
tion
, Com
men
ts, O
bse
rvat
ion
s 6.
D
oes t
he E
xecu
tive
Com
plian
ce C
omm
ittee
mee
t at l
east
qu
arte
rly?
Prov
ide
min
utes
of e
ach
mee
ting.
7.
Doe
s the
Exe
cutiv
e Co
mpl
iance
Com
mitt
ee a
nnua
lly
evalu
ate
itsel
f aga
inst
its c
omm
ittee
cha
rter?
If
yes
, plea
se p
rovi
de.
8.
Is a
n ev
aluat
ion
of th
e Co
mpl
iance
Off
icer a
nd C
ompl
iance
D
irect
or (o
r equ
ivale
nt ti
tle) p
erfo
rmed
, at l
east
ann
ually
, w
ith in
put o
f the
Exe
cutiv
e Co
mpl
iance
Com
mitt
ee?
(the
annu
al pe
rfor
man
ce e
valu
atio
n is
suffi
cient
eve
n if
the
Com
plian
ce O
ffice
r has
man
y ot
her d
uties
) If
yes
, plea
se p
rovi
de.
9.
Doe
s the
Exe
cutiv
e Co
mpl
iance
Com
mitt
ee h
ave
a m
echa
nism
for d
eter
min
ing
that
app
ropr
iate
corr
ectiv
e, re
stor
ativ
e, an
d/or
disc
iplin
ary
actio
n ha
s bee
n ta
ken
for
each
eve
nt o
f non
-com
plian
ce?
If y
es, p
lease
pro
vide
.
10.
Doe
s the
Exe
cutiv
e Co
mpl
iance
Com
mitt
ee a
ppro
ve th
e an
nual
actio
n pl
an?
TH
E U
NIV
ER
SIT
Y O
F T
EX
AS
INST
ITU
TIO
NA
L C
OM
PL
IAN
CE
PR
OG
RA
M S
EL
F-A
SSE
SSM
EN
T
***
FIN
AL
DR
AFT
***
Ver
01/
23/0
8
The
Uni
vers
ity o
f Tex
as C
ompl
ianc
e Se
lf A
sses
smen
t Too
l
Pag
e 3
of 8
N
AC
UA
Fal
l CLE
Wor
ksho
p 20
09 (W
ashi
ngto
n, D
C)
Q
ues
tion
Y
es
No
Doc
um
enta
tion
, Com
men
ts, O
bse
rvat
ion
s
CO
MP
LIA
NC
E O
FF
ICE
R A
ND
FU
NC
TIO
N
11
. Is
the
Com
plian
ce O
ffice
r a h
igh-
rank
ing
adm
inist
rativ
e of
ficer
at t
he in
stitu
tion
who
has
dire
ct a
cces
s to
exec
utiv
e m
anag
emen
t, in
cludi
ng th
e Ch
ief A
dmin
istra
tive
Offi
cer?
12.
Has
the
inst
itutio
n pr
ovid
ed su
fficie
nt re
sour
ces f
or th
e Co
mpl
iance
Offi
cer t
o ad
equa
tely
carr
y-ou
t tho
se fu
nctio
ns
defin
ed in
the
Acti
on P
lan th
at a
re a
pplic
able
to th
e in
stitu
tion?
Budg
et?
St
aff?
Sub-
com
mitt
ees?
Pr
ovid
e or
gani
zatio
n ch
art a
nd b
udge
t.
13.
Do
the
Com
plia
nce
Off
icer
and
eac
h em
ploy
ee in
the
Com
plia
nce
func
tion
have
job
desc
riptio
ns th
at c
larif
y th
e ro
les a
nd sc
ope
of th
e fu
nctio
n?
If y
es, p
lease
pro
vide
.
14.
Doe
s the
Com
plia
nce
Off
ice
mon
itor h
igh-
risk
area
s th
roug
h qu
arte
rly re
ports
, ins
pect
ions
, spo
t-che
cks,
conf
eren
ces,
and/
or re
perf
orm
ance
s?
15.
Has
Com
plian
ce fu
nctio
n st
aff r
eceiv
ed e
xter
nal t
rain
ing
relat
ed to
ope
ratin
g an
inst
itutio
nal c
ompl
iance
pro
gram
? If
yes
, pro
vide
info
rmat
ion
on a
ll su
ch tr
ainin
g, in
cludi
ng
cont
ent,
pres
ente
r, an
d at
tend
ees.
TH
E U
NIV
ER
SIT
Y O
F T
EX
AS
INST
ITU
TIO
NA
L C
OM
PL
IAN
CE
PR
OG
RA
M S
EL
F-A
SSE
SSM
EN
T
***
FIN
AL
DR
AFT
***
Ver
01/
23/0
8
The
Uni
vers
ity o
f Tex
as C
ompl
ianc
e Se
lf A
sses
smen
t Too
l
Pag
e 4
of 8
N
AC
UA
Fal
l CLE
Wor
ksho
p 20
09 (W
ashi
ngto
n, D
C)
Q
ues
tion
Y
es
No
Doc
um
enta
tion
, Com
men
ts, O
bse
rvat
ion
16
. D
oes t
he C
ompl
ianc
e O
ffic
er p
rovi
de re
gula
r upd
ates
on
Com
plia
nce
activ
ities
to th
e C
hief
Adm
inis
trativ
e O
ffic
er?
17.
Doe
s the
Com
plian
ce O
ffice
r pre
pare
and
subm
it th
e fo
llow
ing
repo
rts?
-- M
onth
ly Li
aison
Rep
orts
--
Qua
rterly
and
Ann
ual A
ctiv
ity R
epor
ts
-- A
nnua
l Com
plian
ce A
ctio
n Pl
an
18.
Has
the
Com
plian
ce O
ffice
r ens
ured
that
all
empl
oyee
s hav
e re
ceiv
ed G
ener
al Co
mpl
iance
Tra
inin
g?
If y
es, p
rovi
de a
sum
mar
y re
port
of tr
ainin
g re
cord
s.
19.
Do
all n
ew e
mpl
oyee
s rec
eive
at le
ast 9
0 m
inut
es o
f in-
pers
on g
ener
al co
mpl
iance
train
ing?
20.
Doe
s the
inst
itutio
n ut
ilize
a C
onfid
entia
l Rep
ortin
g M
echa
nism
? If
yes
, pro
vide
a d
escr
iptio
n an
d a
sum
mar
y of
all
activ
ity to
-da
te, i
nclu
ding
the
num
ber o
f rep
orts
rece
ived
to d
ate.
21.
Has
the
Conf
iden
tial R
epor
ting
Mec
hani
sm b
een
com
mun
icate
d to
all
empl
oyee
s?
Des
crib
e th
e va
rious
met
hods
for c
omm
unic
atin
g?
22.
Doe
s the
hot
line
rein
forc
e co
nfid
entia
lity
and
anon
ymity
of
calle
r, th
at th
e ca
ll w
ill n
ot b
e re
cord
ed o
r tra
ced,
and
pr
otec
tion
from
reta
liatio
n?
23.
Is th
ere
a do
cum
ente
d pr
otoc
ol fo
r inv
estig
atin
g re
porte
d in
stan
ces o
f non
-com
plian
ce?
TH
E U
NIV
ER
SIT
Y O
F T
EX
AS
INST
ITU
TIO
NA
L C
OM
PL
IAN
CE
PR
OG
RA
M S
EL
F-A
SSE
SSM
EN
T
***
FIN
AL
DR
AFT
***
Ver
01/
23/0
8
The
Uni
vers
ity o
f Tex
as C
ompl
ianc
e Se
lf A
sses
smen
t Too
l
Pag
e 5
of 8
N
AC
UA
Fal
l CLE
Wor
ksho
p 20
09 (W
ashi
ngto
n, D
C)
Q
ues
tion
Y
es
No
Doc
um
enta
tion
, Com
men
ts, O
bse
rvat
ion
24
. D
o ho
tline
trac
king
doc
umen
ts in
clude
the
date
that
the
repo
rt w
as re
solv
ed?
25.
Has
the
Com
plian
ce O
ffice
r dev
elope
d a
com
plian
ce
man
ual?
If y
es, p
rovi
de.
26.
Do
all e
mpl
oyee
s rec
eive
a pa
per c
opy
of th
e St
anda
rds o
f Co
nduc
t Gui
de (C
ode
of C
ondu
ct)?
27.
Do
all e
mpl
oyee
s sig
n an
ack
now
ledge
men
t tha
t the
y re
ceiv
ed, r
ead,
and
agr
ee to
obe
y th
e ru
les, r
egul
atio
ns,
polic
ies, a
nd p
roce
dure
s out
lined
in th
e St
anda
rds o
f Co
nduc
t Gui
de?
28.
Doe
s the
Sta
ndar
ds o
f Con
duct
Gui
de in
clude
the
proc
ess
for r
epor
ting
inst
ance
s of n
on-c
ompl
iance
?
29.
Whe
n w
as th
e St
anda
rds o
f Con
duct
Gui
de la
st u
pdat
ed?
Are
all
chan
ges t
o th
e St
anda
rds o
f Con
duct
Gui
de a
ppro
ved
by e
xecu
tive
com
plian
ce c
omm
ittee
?
TH
E U
NIV
ER
SIT
Y O
F T
EX
AS
INST
ITU
TIO
NA
L C
OM
PL
IAN
CE
PR
OG
RA
M S
EL
F-A
SSE
SSM
EN
T
***
FIN
AL
DR
AFT
***
Ver
01/
23/0
8
The
Uni
vers
ity o
f Tex
as C
ompl
ianc
e Se
lf A
sses
smen
t Too
l
Pag
e 6
of 8
N
AC
UA
Fal
l CLE
Wor
ksho
p 20
09 (W
ashi
ngto
n, D
C)
Qu
esti
on
Yes
N
o D
ocu
men
tati
on, C
omm
ents
, Ob
serv
atio
ns
R
ISK
ASS
ESS
ME
NT
PR
OC
ESS
30.
Has
an
asse
ssm
ent o
f com
plian
ce ri
sks a
pplic
able
to th
e in
stitu
tion
been
per
form
ed?
Fe
dera
l?
Stat
e?
Lo
cal?
Re
gulat
ors/
Acc
redi
tors
?
UT
Syst
em?
In
stitu
tiona
l? If
yes
, pro
vide
.
31.
Was
the
risk
asse
ssm
ent p
erfo
rmed
by
Su
b-co
mm
ittee
s?
Fu
nctio
nal D
epar
tmen
ts?
M
anag
emen
t?
32.
Wer
e all
com
plian
ce ri
sks i
nclu
ded,
eve
n th
ose
that
the
inst
itutio
n be
lieve
s are
ade
quat
ely c
ontro
lled?
If
no,
pro
vide
a li
st o
f tho
se ri
sks n
ot in
clude
d in
the
inve
ntor
y fo
r any
reas
on.
33.
Has
the
pote
ntial
impa
ct a
nd p
roba
bilit
y of
occ
urre
nce
been
es
timat
ed fo
r eac
h ris
k lis
ted?
If
yes
, pro
vide
the
met
hodo
logy
for a
ssig
ning
thes
e va
lues
.
34.
Has
a m
etho
dolo
gy b
een
esta
blish
ed fo
r det
erm
inin
g hi
gh-
risk
item
s?
If y
es, p
rovi
de th
e m
etho
dolo
gy a
nd th
e re
sulta
nt li
st.
TH
E U
NIV
ER
SIT
Y O
F T
EX
AS
INST
ITU
TIO
NA
L C
OM
PL
IAN
CE
PR
OG
RA
M S
EL
F-A
SSE
SSM
EN
T
***
FIN
AL
DR
AFT
***
Ver
01/
23/0
8
The
Uni
vers
ity o
f Tex
as C
ompl
ianc
e Se
lf A
sses
smen
t Too
l
Pag
e 7
of 8
N
AC
UA
Fal
l CLE
Wor
ksho
p 20
09 (W
ashi
ngto
n, D
C)
Qu
esti
on
Yes
N
o D
ocu
men
tati
on, C
omm
ents
, Ob
serv
atio
ns
M
ON
ITO
RIN
G, R
EP
OR
TIN
G, A
ND
SP
EC
IAL
IZE
D
TR
AIN
ING
PL
AN
S
35.
Has
a si
ngle
resp
onsib
le pe
rson
bee
n de
signa
ted
for e
ach
high
-risk
?
36.
Has
a m
onito
ring
plan
bee
n de
velo
ped
for t
he ri
sk?
37
. D
oes t
he m
onito
ring
plan
des
crib
e w
hat o
pera
ting
cont
rols
will
be
mon
itore
d?
38.
Doe
s the
mon
itorin
g pl
an d
etail
the
actio
ns to
be
take
n to
de
term
ine
whe
ther
or n
ot th
e op
erat
ing
cont
rols
wer
e ap
plied
cor
rect
ly?
39.
Is th
ere
docu
men
ted
evid
ence
that
the
mon
itorin
g co
ntro
ls w
ere
perf
orm
ed?
40.
Is th
ere
docu
men
ted
evid
ence
of t
he re
sults
of t
he
mon
itorin
g co
ntro
ls?
41.
Is th
ere
docu
men
ted
evid
ence
of a
ctio
ns ta
ken
whe
n m
onito
ring
cont
rols
iden
tify
failu
re o
f ope
ratin
g co
ntro
ls?
42.
Are
inst
ance
s of n
on-c
ompl
iance
doc
umen
ted
and
dealt
with
ap
prop
riate
ly?
43.
Are
inst
ance
s of n
on-c
ompl
iance
or p
oten
tial n
on-
com
plian
ce re
porte
d to
the
Exe
cutiv
e Co
mpl
iance
Co
mm
ittee
and
to th
e Ch
ief A
dmin
istra
tive
Offi
cer?
44.
Has
spec
ializ
ed tr
ainin
g re
lativ
e to
miti
gatio
n of
this
risk
been
pro
vide
d to
em
ploy
ees w
ho in
tera
ct w
ith th
e ris
k?
Is d
ocum
enta
tion
of a
ttend
ance
mai
ntai
ned?
45.
Doe
s the
Com
plian
ce O
ffice
mon
itor r
ecor
ds fo
r spe
cializ
ed
train
ing?
46.
Doe
s the
Com
plian
ce O
ffic
e co
nduc
t vali
datio
n/as
sura
nce
activ
ities
on
inst
itutio
nal h
igh
risk
area
s?
TH
E U
NIV
ER
SIT
Y O
F T
EX
AS
INST
ITU
TIO
NA
L C
OM
PL
IAN
CE
PR
OG
RA
M S
EL
F-A
SSE
SSM
EN
T
***
FIN
AL
DR
AFT
***
Ver
01/
23/0
8
The
Uni
vers
ity o
f Tex
as C
ompl
ianc
e Se
lf A
sses
smen
t Too
l
Pag
e 8
of 8
N
AC
UA
Fal
l CLE
Wor
ksho
p 20
09 (W
ashi
ngto
n, D
C)
Qu
esti
on
Yes
N
o D
ocu
men
tati
on, C
omm
ents
, Ob
serv
atio
ns
47.
Has
doc
umen
ted
spec
ializ
ed tr
ainin
g be
en p
rovi
ded
in e
ach
case
of f
ailur
e of
ope
ratin
g co
ntro
ls or
inst
ance
s of n
on-
com
plian
ce w
here
lack
of t
rain
ing
is fo
und
to b
e th
e ro
ot
caus
e of
the
failu
re?
48.
Do
the
high
-risk
are
a re
spon
sible
pers
ons p
rovi
de re
ports
to
the
Com
plian
ce O
ffice
r and
the
Com
plian
ce C
omm
ittee
? W
hat i
s the
freq
uenc
y of
thes
e re
ports
?
Q
ues
tion
Y
es
No
Doc
um
enta
tion
, Com
men
ts, O
bse
rvat
ion
s
INT
ER
NA
L A
UD
ITIN
G
49
. H
as in
tern
al au
dit p
erfo
rmed
any
aud
its in
volv
ing
com
plian
ce h
igh-
risk
area
s?