Business Procedures Manual

Essential business procedural components for University System of Georgia institutions.

16.5 Ethics & Compliance

16.5.1 Overview & Applicability

(Last Modified on August 14, 2020)

It is the policy of the University System of Georgia (USG) to comply with applicable laws, rules, and regulations and to encourage ethical conduct as detailed in the USG Ethics Policy (see Board Policy 8.2.18.1 USG Ethics Policy). The USG Ethics and Compliance Program (Program) refers to the USG policies, procedures, and trainings designed to ensure ethical conduct and compliance with applicable laws, rules and regulations. The Ethics and Compliance Policy applies to all USG institutions and the University System Office.

Adhering to federal guidelines is also important for an effective ethics and compliance program. These guidelines prescribe two overarching requirements:

  1. An organization shall exercise due diligence to prevent and detect criminal conduct, and
  2. An organization shall otherwise promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.

16.5.2 Objectives

(Last Modified on August 14, 2020)

Program objectives are to:

  1. Identify applicable laws, regulations, policies, and contractual requirements which pertain to each institution and to the USG;
  2. Assess compliance risks and manage accordingly;
  3. Ensure that responsibility for ensuring compliance has been properly assigned to responsible personnel;
  4. Monitor compliance with applicable requirements; and,
  5. Provide training and expertise to meet compliance requirements.

16.5.3 Framework

(Last Modified on August 14, 2020)

An effective Program is designed to meet the following elements and ensure that:

  1. Standards of Conduct: Standards have been adopted that require compliance with applicable law;
  2. Oversight by Senior Leadership: High-level personnel have been assigned the authority and responsibility to implement the Program and ensure that the Board of Regents (BOR) is periodically updated on Program status;
  3. Accountability of Senior Leadership: Individuals with substantial discretionary authority and/or charged with implementing the Program have not engaged in illegal activities or other conduct inconsistent with an effective compliance program;
  4. Training & Awareness: Program requirements and ethical standards are periodically communicated to all employees through effective training and regular communication;
  5. Monitoring, Evaluating and Reporting: Effective monitoring is implemented to detect misconduct, evaluate Program effectiveness, and provide a reporting system whereby employees can report misconduct without fear of retribution;
  6. Enforcement of Standards: Program standards are enforced through appropriate incentives and sanctions; and,
  7. Ongoing Program Improvements: Responses to misconduct are appropriate and reasonable steps are taken to prevent further offenses to include modifying the Program to prevent and detect violations of the law.

16.5.4 Administration and Responsibility for the Ethics and Compliance Hotline

(Last Modified on August 14, 2020)

The president of each institution shall appoint an administrator who will serve as the Ethics and Compliance Reporting Hotline Coordinator. Each USG institution is encouraged to establish a triage committee to review and manage reports received on the hotline. Triage committee members may include representatives from internal audit, the office of legal affairs, compliance, human resources, public safety/campus police, information security or other functions at the discretion of the institutional president. However, all reports received regarding potential fraud, waste and abuse must be provided to the internal audit department.

If a triage committee is established, it is this committee’s responsibility to monitor the institutional Ethics and Compliance Reporting Hotline and to ensure appropriate remediation of hotline issues. Absent a formal triage committee, the Hotline Coordinator is responsible for ensuring compliance with this section. Issues involving members of the triage committee or institutional executive management shall be referred to the USG Office of Internal Audit and Compliance for remediation and/or investigation.


16.5.5 Implementation

(Last Modified on August 14, 2020)

An institution-wide approach to compliance shall be adopted by all USG institutions. Compliance processes must be embedded into the institution’s management systems and processes. Each institution President or designee shall develop a campus compliance framework and associated procedures to:

  1. Identify and document key regulatory and compliance areas;
  2. Assess compliance risks to determine appropriate management action(s);
  3. Identify management infrastructure and/or oversight committees within the institution that have responsibility for ensuring compliance with identified regulatory and compliance areas, as applicable, (examples may include athletics, research (including human subject research), finance and administration, and programs serving non-student minors);
  4. Develop risk and mitigation strategies and steps to implement them;
  5. Provide initial and ongoing compliance and education training;
  6. Provide for systematic assessments to evaluate and audit compliance and report on progress;
  7. Communicate compliance ownership and significant or revised regulations to oversight committees, management and stakeholders.

16.5.6 Accountability

(Last Modified on August 14, 2020)

There are multiple offices within the USG that have responsibility for compliance activities. The Chancellor shall designate a position responsible for coordinating the Program system-wide.


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