The University will comply with federal, state, and other regulations. The Executive Vice President & Chief Operating Officer (EVP&COO) is the University’s Institutional Compliance Officer.

The University’s institutional compliance program provides oversight of major compliance areas in specific functions of the University managed by members of the Compliance Network.

Vice Presidents and equivalent officers are responsible for establishing and overseeing compliance programs within their functional areas, and reporting significant issues to their respective EVP, the EVP&COO, and the Assistant Vice President for Compliance. The University’s compliance efforts will be evaluated through the services of external and internal auditors, the Office of University Counsel, as well as periodic assessments by management.

All faculty, staff, Medical Center employees, and other individuals associated with the University or the Medical Center (e.g., contractors, vendors, volunteers, student employees and others while working or acting on behalf of the University or the Medical Center) must report all known or suspected violations of law or University policy, without fear of retaliation for reports made in good faith, and cooperate with all investigations into suspected wrongdoing. A list of university reporting portals is available at report.virginia.edu.

The University prohibits retaliation against any individual who makes a good faith report of suspected wrongful conduct pursuant to this policy or related federal or state laws.

As stated in the University of Virginia Compliance Charter, approved by the Board of Visitors, “(t)he Assistant Vice President for Compliance, with strict accountability for confidentiality and safeguarding of records and information, is authorized to have full, free, and unrestricted access to any and all of the University’s records, physical properties, and personnel pertinent to carrying out compliance investigations, and to review and monitor compliance issues. All employees are requested to assist the compliance function in fulfilling its roles and responsibilities.”

While adherence to these principles applies to all divisions of the University, there are separate compliance offices that focus on UVA Health and UVA Wise:

• UVA Medical Center (and UVA Health entities) operates a healthcare-specific Compliance Program, in accordance with the Department of Health and Human Services’ Office of Inspector General’s “General Compliance Program Guidance” (Nov. 2023), as described in the UVA Health Compliance Plan, UVA Health and facility-specific compliance policies, and UVA Health Compliance Code of Conduct, available through the UVA Health Corporate Compliance & Privacy Office.
• UVA Wise is committed to operating with integrity and honor in full compliance with all applicable federal and state laws and regulations, as well as College policies. UVA Wise works to promote campus compliance with applicable laws, regulations and policies, keep the campus community informed of compliance information and resources, support the coordination of campus compliance activities, provide updates to the campus community regarding required guidelines and mandates, and promote a campus culture of ethical conduct, mutual respect and inclusiveness. The following webpage is available for reporting information regarding incidents or concerning behavior at UVA Wise.

1. Compliance Program Standards:
   The University has established standards for individual compliance programs, based on the criteria used in the Federal Sentencing Guidelines, the current version of which includes the following:
   1. Compliance standards and procedures to prevent and detect criminal activity.
   2. Oversight by high-level personnel, with periodic reporting to the board from individuals with operational responsibility.
   3. Due care in delegating substantial discretionary authority.
   4. Effective communication and training to all levels of employees.
   5. Systems for monitoring, auditing, and reporting suspected wrong-doing without fear of reprisal and for periodically evaluating the effectiveness of the compliance program.
   6. Consistent enforcement of compliance standards including disciplinary mechanisms and appropriate incentives to perform in accordance with the compliance program.
   7. Reasonable steps to respond to and prevent further similar offenses upon detection of a violation.
   8. Periodic reassessment of the compliance program in order to strengthen controls and reduce criminal conduct.
2. Responsibilities:
   1. The Executive Vice President & Chief Operating Officer will:
      • Approve compliance policies, upon recommendation by the University’s Policy Review Committee and the Assistant Vice President for Compliance.
   2. The Assistant Vice President for Compliance will:
      • Oversee all compliance functions, including but not limited to:
        • Confirming that the University maintains compliance programs across the University that address applicable laws, meet University standards, and are consistently managed and documented.
        • Coordinating communication and monitoring activities in connection with the corporate compliance program.
        • Overseeing the implementation of corrective actions to be taken when deemed necessary.
      • Report to and consult with the Chief Audit Executive and Executive Vice President & Chief Operating Officer on significant compliance issues.
      • Provide reports on compliance matters to the Board of Visitors.
   3. The Vice Presidents (and Equivalent Officers) will:
      • Oversee compliance in their specific functional areas.
      • Designate individuals within their units as compliance officers who will be responsible for compliance activities.
      • Adhere to the University compliance program standards outlined in Section 1, Compliance Program Standards, above.
      • Implement or recommend corrective action as necessary.
      • Report significant compliance issues to the University’s EVP&COO, their respective Executive Vice President, and the Assistant Vice President for Compliance.
   4. Compliance Officers will:
      • Report to the Vice President of their unit regarding both operational and compliance matters.
      • With guidance from the Vice President to whom they report:
        • Develop appropriate policies and procedures to enable compliance with rules and regulations.
        • Train and communicate on compliance issues.
        • Maintain required documentation (e.g., of training completed).
        • Use feedback (including detected violations) to make improvements.
      • Recommend corrective action as appropriate.
      • Report to and consult with the Assistant Vice President for Compliance and their respective Vice President (and equivalent officers) on significant compliance issues, reporting requirements, and external compliance reviews. Any serious issues must also be reported to the Executive Vice President and Chief Operating Officer and their respective Executive Vice President.
   5. Operational Managers will:
      • Implement policies and procedures to enable compliance with rules and regulations.
      • Implement corrective actions when necessary.
      • Provide reports to the relevant compliance officer or Vice President about compliance issues requiring attention.
   6. All Persons - All faculty, staff, Medical Center employees, and other individuals associated with the University or the Medical Center (e.g., contractors, vendors, volunteers, student employees and others while working or acting on behalf of the University or the Medical Center) will:
      • Act ethically and honestly, in accordance with all applicable laws, regulations, policies, and codes of conduct.
      • Seek guidance on any possible compliance issues from either:
        • Their supervisor
        • Office responsible for the subject-specific compliance area
        • Assistant Vice President for Compliance, UVA Health’s Chief Corporate Compliance and Privacy Officer, or UVA Wise Vice Chancellor and Chief of Staff.
      • Cooperate fully with individuals performing investigations by providing all requested documentation and answering all questions truthfully and completely.
      • Report all compliance-related concerns to the Compliance Helpline (complete webform at report.virginia.edu or call 800-235-8700). Reports to the Compliance Helpline may be made anonymously, if desired.

3. Compliance with Policy:
   Failure to comply with the requirements of this policy may result in disciplinary action up to and including termination or expulsion in accordance with relevant University policies. Additionally, non-compliance with federal, state, and other regulations related to operations may result in fines, penalties, and other legal action.

   Questions about this policy should be directed to the Compliance Office.