PUBLIC HEALTH DEPARTMENT
Policy Number:
Supersedes:
#
Effective Date:
N/A
Next Review Date:
00/__/12
Accountable:
00/__/12
(Signature of Health Department Director)
Typed Name, Director
[insert the title of the
person accountable
for executing the
policy]
Cross Reference:
N/A
Policy Creation
APPLIES TO:
STATEMENT OF PURPOSE:
The Health Department expects its associates to operate in accordance with duly enacted
policies and procedures. These policies and procedures/protocols provide guidance to
associates in their day-to-day activities; ensure compliance with applicable federal and
state laws; and support and fulfill the operation, and mission of the Health Department.
DEFINITIONS:
A. Policy: A course of action or a principle that guides and determines present and
future decision-making. Policy reflects the philosophy upon which (name of
organization) operates.
B. Procedure/Protocol: A guideline for how Health Department policies are to be
carried out.
ATTACHMENTS:
ATTACHMENT 1 – Health Department Policy Format
ATTACHMENT 2 – Policy Approval Signature Sheet
PROCEDURE:
A. Health Department Policy Development and Revision:
1. New policies and policy revisions may originate by a request from the
Health Department leadership or a recognized need for a policy revision
among any associate.
2. Policies will generally be drafted by an associate in the work unit to which
the policy applies, with assistance and/or input from other work units as
needed.
3. The proposed policy must be reviewed by the Health Department Director
and approved by the Health Department member whose operating area the
policy affects.
4. After the policy is reviewed and approved, it will be sent to the Health
Department Director for his/her approval.
5. Policies are effective upon approval by the Health Department Director
unless otherwise noted.
6. The required approvals may be received via email and the approving email
must be attached to the policy approval signature sheet.
B. Archiving of (name of organization) Policies
1. The _____________________ (name of department) shall be accountable
for ensuring that policies are placed on the (name of organization) intranet
in a timely manner.
2. The _____________________ (name of department) shall also keep a copy
(either electronic or hard copy) of each policy and subsequent revisions.
3. All policies shall be saved in the following format: policy number,
policy name, date of policy. For example, this policy is saved as 2.1
Policy Creation 1.17.11. (this can be changed)
C. All Health Department policies should be reviewed annually and revised as
appropriate by the affected division or the appropriate (department overseeing
policies).
Policy Title:
Policy No:
Date:
Page of
PUBLIC HEALTH DEPARTMENT
Policy Number:
Supersedes:
#
Effective Date:
N/A
Next Review Date:
00/__/12
Accountable:
00/__/12
(Signature of Health Department Director)
Typed Name, Director
[insert the title of the
person accountable
for executing the
policy]
Cross Reference:
[Note any
policy/procedure/statute,
etc. that is related to this
procedure]
Policy Creation
APPLIES TO:
STATEMENT OF PURPOSE:
A brief statement on the purpose of the policy.
DEFINITIONS:
Use this portion to define any terms located in the policy.
PROCEDURE:
A high level explanation of how the policy is carried out. More specific explanations
may require the drafting of a procedure.
VIOLATIONS AND ENFORCEMENT:
A high level explanation of how the policy is enforced and what happens if policy is
violated. More specific explanations may require the drafting of a procedure/protocol.
LEGAL AUTHORITY/REFERENCES:
List of who/what the legal authority is as it relates to this policy and cite applicable
references.
DISTRIBUTION/TRAINING REQUIREMENTS:
Explanation of training requirements required to meet the policy>
ATTACHMENTS:
List all attachments.
Title:
Policy No:
Date:
Page of
Sample Attachment Format
Header should include the following in the top right hand corner of the attachment:
Policy No:
Attachment # (1, 2, 3, etc.)
Date:
Policy Approval
Date:_______________________________________________
Policy Title: _________________________________________
Policy Number:_______________________________________
[Health Department Manager (whose area the policy applies]
_______________________ ______________________________________
Name & Title
Signature
_____________
Date
Health Department Head (who oversees policies):
_______________________ ______________________________________
Name
Signature
_____________
Date
Legal Reviewer (as required):
_______________________ ______________________________________
Name
Signature
_____________
Date
Health Department Director :
_______________________ ______________________________________
Name
Signature
_____________
Date
Board of Health (as required):
_______________________ ______________________________________
Name
Signature
_____________
Date