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Policy Framework

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Section 1 - Introduction

(1) The University of Newcastle (University) is committed to effective governance and control over its operations, in accordance with the University of Newcastle Act 1989 and the University of Newcastle By-Law, 2017.

(2) This document provides a framework for the development, approval, implementation, review, and ongoing management of University policy documents.

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Section 2 - Purpose

(3) This framework documents the required processes for development, review and rescission of University policy documents to ensure they are:

  1. drafted in a collaborative manner and in consideration of risks and opportunities;
  2. approved by the appropriate delegate;
  3. implemented and communicated to ensure effective operationalisation; and
  4. reviewed in a timely manner to ensure ongoing relevance, currency and effectiveness.
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Section 3 - Scope

(4) This framework applies to all policy documents that are identified in the Hierarchy of University Policy Documents and published in the University policy library.

(5) The University policy library contains the following types of policy documents:

Table 1 – Types of Policy Documents

Type of Policy Document Purpose of Document
Rule A Council approved document, made in accordance with Section 29 of the University of Newcastle Act, that has the same force and effect as a by-law.
Policy A document that conveys the University's intent (on the basis of principles) on a particular subject or matter, and how associated risks and opportunities must be addressed.
Framework A document that addresses how a wide-reaching activity is undertaken at an enterprise or organisation level through policy and procedure provisions.
Procedure Establishes a logical sequence of consecutive actions to achieve a desired output, or series of outputs.
Manual Provides a group of policies and/or procedures that are related to each other. A manual must clearly identify policy content as separate to procedure content.
Guideline Provides supporting information that a reader can choose to comply with. The content is aimed at helping the reader make a decision or guiding their action.
Schedule Provides information to support a policy, procedure or manual.
Code Establishes expectations of behaviour.

(6) Other types of documents are not permitted to be published as a policy document in the University Policy library.

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Section 4 - Definitions

(7) In the context of this document:

  1. “approval authority” refers to a delegate who has delegated or sub-delegated authority to approve a policy document;
  2. “policy document” is a collective term that refers to any document listed in Table 1 of this Framework, unless otherwise specified;
  3. “Policy Owner” refers to the position that is responsible for the operational implementation and review of a policy document; and
  4. “Policy Author” refers to the person(s) who will draft the policy document;
  5. “Responsible Executive” refers to the senior executive who holds ultimate accountability for the policy document;
  6. “Subject matter expert” refers to a staff member who can provide the knowledge and expertise on the subject that the policy document relates to.
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Section 5 - Hierarchy of Documents

(8) The University's approved hierarchy of documents is represented in the Hierarchy of University Policy Documents. The level of a document within the hierarchy equates to the binding capacity of the document (i.e. the higher the document in the hierarchy, the more binding it is).

(9) Policy documents lower in the hierarchy must be consistent with higher level documents, and associated legislation and regulations.

(10) Where an inconsistency between policy documents may exist, the highest level document in the hierarchy will prevail.

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Section 6 - Policy Development

Determining the Need for a Policy Document

(11) The need for a policy document should be based on:

  1. an understanding of the subject and its context, including risks and opportunities related to the subject;
  2. the University's intent and approach to the subject;
  3. the factors or events that have triggered the need for a policy document; and
  4. an assessment of the current documents (including existing policy documents, legislation, standards etc) that address the subject.

(12) The greater the risk associated with the subject the more likely that a policy or procedure is required. For lesser risks the subject could be addressed through other means not reflected in the Policy Library, such as a strategy or plan, a webpage, or a one-off communication to stakeholders.

(13) A policy document should only be developed where the University is committed to, and able to fully implement the document and its requirements to achieve compliance.

(14) Table 2 provides examples of when a policy document may be required.

Table 2 – Examples of when a Policy document may be required

Type of Policy Document Examples of when it may be required
To achieve consistency and make requirements legally binding.
To establish the University's requirements for highly sensitive or contentious issues.
When compliance is critical to the University's operations, administration, governance or reputation.
Where legal protection is required.
If legislative (or contractual) obligations need to be complied with across the whole of the University.
Consistent and fair treatment of staff / students is desirable.
The University's intended approach to a risk / opportunity needs to be established and agreed upon.
To achieve consistency in managing an issue that is generic to all business, and is wide-reaching, such as an element of governance.
Establish an agreed approach.
A collaborative and coordinated approach is essential.
Many stakeholders may undertake the same activity (such as risk management) but may need some flexibility in the ‘how’ whilst still achieving a desired result.
The quality, timing, or quantity of output of a process will impact on staff, students or the University.
Consistency in process is critical to achieving the desired output.
There is benefit in clarifying what is required, when, and by whom.
When a process is lengthy, complex, involves more than a few stakeholders, or may change regularly.
Guideline Readers need specific information to understand a subject and use this information to make a decision.
Schedule Information needs to be listed or communicated; or readers need information that is relative to their work or relative to the University's objectives or obligations.
Code The University wishes to establish expected standards of behaviour.
Manual There are a number of policies and related procedures that could be grouped together to inform readers regarding a wider process or system.

Assessment of Risk and Opportunity

(15) The development of a policy document should be based on an assessment of risk and opportunity to highlight the critical issues that the document may deal with, and to allow a better understanding of the subject to inform its content.

Engagement with Governance and Assurance Services

(16) Governance and Assurance Services are responsible for administering the Policy Library and Delegations Register; and for ensuring compliance with this Framework.

(17) The Policy and Delegations Officer is the first point of contact when it is determined that a new policy document should be developed. Contact should be made to:

  1. discuss the background of the subject;
  2. determine if a policy document is the most appropriate approach;
  3. identify if any current policy documents deal with the subject; 
  4. determine the most appropriate type of policy document; and
  5. discuss consultation and approval pathways.

(18) The Policy and Delegations Officer must obtain approval from the University Secretary to proceed with the development of a new policy document. Once approved, the Policy and Delegations Officer must obtain confirmation of who will be the Policy Owner, Policy Author, and Enquiry Contact Person and then create a draft document for the commencement of drafting in the software workspace.

(19) The Policy and Delegations Officer will provide advice and assistance to the Policy Author to support the development work.

Review of Associated Legislation and Policy Documents

(20) Prior to the commencement of drafting, the Policy Owner or Policy Author must identify and become familiar with any relevant or associated legislation, University Policy documents, and the University Strategic Plan so there will be no repetition, overlap, or inconsistencies in the document being drafted.


(21) Consultation with key stakeholders during the policy development process is critical for:

  1. understanding the context in which the document will impact, including associated risks and opportunities;
  2. identifying potential or actual problems and solutions;
  3. gathering knowledge, experiences, and perspectives; and
  4. building credibility and legitimacy of the document.

(22) The Policy Owner or Policy Author must identify all relevant key stakeholders and undertake consultation with these stakeholders as part of the assessment of risk and opportunity. Ongoing consultation with key stakeholders must occur throughout the drafting phase to ensure that all stakeholders are in agreement, where possible, with the final draft. The Policy Consultation Guideline provides information that can support an effective consultation process.

(23) The Legal and Compliance unit must be consulted where the subject matter relates to legislation, where a Rule is being developed or reviewed, or where any legal risk is identified.

(24) The Policy Consultation Guideline provides further information on consultation and how it may be undertaken.


(25) Authors must undergo a Policy Library Workspace introduction session prior to commencing drafting in the policy library workspace. The Policy and Delegations Officer will provide this session.

(26) Drafting should, wherever possible, occur within the policy library workspace. Where a valid reason for not using the workspace is identified, the Policy and Delegations Officer must be notified.

(27) Only one Policy Author is able to work in a policy draft in the policy library workspace at one time. Where a number of Policy Author(s) may be drafting the document, the Policy and Delegations Officer will need to be advised whenever a change in Policy Author is required, to provide the new author with access to the draft document.

(28) The Policy Style Guide provides supporting information to assist Policy Authors when drafting.

Quality Review and Final Consultation

(29) When a final draft has been agreed upon by the Policy Owner and Policy Author, the document must be forwarded to the Policy and Delegations Officer for review prior to it being submitted for approval. The purpose of this review is to:

  1. provide a quality review of the document; and
  2. ensure that the content does not conflict or duplicate any other Policy documents.

(30) Further amendments may be recommended following the above review. Policies submitted for approval via committees without a Governance and Assurance Services review may be rejected from committee meeting agendas.

(31) Consultation should occur with relevant stakeholders once a final draft is agreed upon. The Bulletin Board within the University Policy Library may be used to seek this feedback. The Policy and Delegations Officer can advise on the function of the Bulletin Board and the feedback workflow it provides. Draft documents should not be placed on the Bulletin Board prior to a quality review being conducted by the Policy and Delegations Officer.

Consultation Record Keeping

(32) Policy Authors and Policy Owners are required to maintain records of all consultation undertaken, and submit a summary of this consultation with the draft document when being submitted for approval.

(33) The Policy Consultation Appendix template can be used for this purpose.

Implementation Plan

(34) Where the publication of a policy document may have a wide ranging impact on the University, an implementation plan may be necessary, and may be recommended or sought by Governance and Assurance Services prior to finalising their quality review.

(35) An implementation plan should identify what actions are required, and by whom, to successfully implement and comply with the policy. This may include, but is not limited to:

  1. communications;
  2. training;
  3. changing or updating resources;
  4. changing practices and review of these to ensure compliance; and
  5. seeking new delegated authorities, or changes to existing delegated authorities.

(36) Please see the Implementation Plan template.

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Section 7 - Approval of Policy Documents

(37) All policy documents must be approved in accordance with the University's delegations prior to their publication and implementation. (Please see Delegations Register). 

(38) The Policy and Delegations Officer can provide support and assistance in identifying the appropriate approval pathway and approval authority.

(39) Prior to submitting a policy document for approval, the following must be undertaken:

  1. identification and preparation of all associated information that will be linked to in the policy library;
  2. completion of a paper for submission for approval, and if necessary, cycle through the appropriate committees for recommendation or endorsement, including preparation of appropriate resolution(s). (See Council – templates, guides and resources); and
  3. where the document has been drafted outside of the policy library workspace, the final content being submitted for approval must be provided to the Policy and Delegations Officer for transfer into the workspace so that the draft that is submitted for approval will be the document that is published once it is approved.

(40) The paper for submission for approval must include, at a minimum:

  1. a draft resolution seeking specific approval from the appropriate delegate of the policy document (using the Policy Document title);
  2. details of the need for the Policy document;
  3. details of consultation that has occurred (See Policy Consultation Appendix template) ;
  4. the expected review period (see clause 47);
  5. the Implementation Plan (if required) (as an appendix); and
  6. the draft Policy as an appendix.

(41) Draft resolutions provided on the paper for submission for approval must also be considerate of any related matter that may require approval to give effect to the policy. For example, where approval of a new policy document will result in the rescission of another policy, approval should be sought for the rescission at the same time, providing both approvals can be provided by the same delegate.


(42) A record of confirmation of approval must be provided to the Policy and Delegations Officer to enable publication of the approved document. 

(43) The University Secretary may authorise publication of a policy document without confirmation where the provision of the confirmation may be delayed but immediate publication is necessary.

(44) Publication of draft policy documents without confirmation of approval may be delayed until such evidence can be sourced from Secretariat.

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Section 8 - Policy Implementation


(45) The Policy and Delegations Officer will publish approved policy documents upon receipt of the confirmation of approval from the relevant approval authority.

(46) The effective date of the policy document will be the date of publication, or a later date. Backdating of policy documents is not permitted.

(47) A Policy Document must not be published in any form other than the accepted University Policy library unless a valid reason exists and approval from the University Secretary is obtained.

(48) The review date of a Policy document will default to 3 years, unless approved to be otherwise.  The minimum review period will be 12 months; and the maximum review period will be 5 years (See Section 9 – Policy Review).

Communication and Implementation

(49) Once published, the Policy and Delegations Officer will notify the Policy Author of the publication. The
Policy Owner is responsible for ensuring that any communication and implementation actions are then completed.


(50) The Policy Owner, or their nominee, is responsible for monitoring the appropriateness and effectiveness of the policy document.

Editorial Amendments

(51) An editorial amendment is an amendment to a title or naming convention, updating hyperlink(s), correcting an inaccurate reference, or rectification of a typographical error. An editorial amendment to a position title is limited to changes where there has been no change to responsibilities.

(52) Requests for editorial amendments should be sent to in the first instance.

Minor Amendments

(53) A minor amendment is a change to a policy document that is of an insubstantial nature, not affecting the principles or intent of the policy. Minor amendments may affect responsibilities or operational aspects of processes. 

(54) Requests to make a minor amendment to a policy document should be sent to in the first instance. The Policy and Delegations Officer will make a determination on the approval pathway of the amendment requested. All approved and published minor amendments must be:

  1. reported to Executive Leadership Team by the Policy and Delegations Officer if approved by a delegate without Executive Leadership Team's endorsement; or
  2. reported to Academic Senate if approved under President Academic Senate's delegated authority
  3. recorded in the status and details of the policy document; and
  4. reflected in the policy document record management file held within the University's approved record management system.

(55) Minor amendments to Rules must be approved by Council prior to publication.

(56) Where a minor amendment may also impact on the delegations register (such as to a position title), the Policy and Delegations Officer will consult with an appropriate Senior staff member to gain an understanding of the position title change in relation to any authority sub-delegated to the position prior to effecting any change in the policy library database.

Issues Register

(57) Policy Owners are responsible for maintaining a Policy Issues Register to record any issues identified with the policy. The register should be reviewed to inform any future policy review.

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Section 9 - Policy Review

(58) In general, policy documents must be reviewed every three (3) years. Some documents, however, may be required to be reviewed on a more regular basis, or a longer basis (maximum of 5 years), depending on the subject matter and associated risks.

(59) The Responsible Executive is responsible for ensuring the policy review is completed in a timely manner, with the aim of completing the review within 6 months of the review date.

Assessment of Change and Consistency

(60) Review of a policy document should entail a full assessment of changes that may have occurred during the period that the document has been published. This assessment should include a review of:

  1. all associated information, including legislation;
  2. industry best practice, changes or developments (where relevant);
  3. roles, titles, communication, and reporting lines;
  4. the University strategic plan; and
  5. current practices and processes.

(61) A review of the policy issues register and consultation with key stakeholders must be undertaken as part of the above assessment (see Policy Consultation Guideline).

Residual Risk Assessment / Risk Based Thinking

(62) The review of a policy should involve determining if the original risks have been mitigated, and if the residual risk remains acceptable to the University. A review of any associated internal audit findings may assist with this, where they are available. Where an unacceptable residual risk remains the Policy Owner should consider further implementation activities post approval of the revised document.

(63) A policy review should also gather information to determine if the original objective of the policy has been achieved, if the document has been implemented as intended, and if it is having the desired effect.

Determining the Ongoing Need

(64) The policy review should consider whether the document is still required and relevant, or if the content could be consolidated with another document, or be in another format.

Edit and Review

(65) To revise a policy document that is due for review, contact should be made with the Policy and Delegations Officer to discuss the review process, and arrange for a draft document to be made available to the Policy Author in the policy library workspace.

(66) The edit and review process must be undertaken in a timely manner to ensure that the content remains current throughout the review.

(67) The Policy and Delegations Officer can provide support and assistance in completing the review, and should be provided with regular updates to inform of actions taken to finalise the policy review.

(68) Revised policy documents must undergo the same review and consultation processes as for new policy documents as outlined above.

Approval and Implementation

(69) The approval and implementation of a revised policy must comply with Section 7 and 8 of this framework, unless the existing content requires no changes.

No Change Review

(70) If after reviewing a policy document it is determined that no changes are required, an email should be sent to the Policy and Delegations Officer ( to request the policy review date be extended for a further period. The Policy and Delegations Officer will undertake a quality review of the policy document, and may seek approval from the University Secretary or an appropriate delegate for approval of the review date extension. The Policy Owner will be advised accordingly.


(71) Rescission of a policy document from the policy library must be approved by a delegate, and a copy of this approval provided to the Policy and Delegations Officer.

(72) The Policy and Delegations Officer is responsible for removing the rescinded policy from the policy library. Where the rescinded document may be referred to in other policy documents, rescission of the policy may be dependent upon approval of amendments to the linked policy documents.

(73) The Policy Owner is responsible for communicating rescission of the policy document to all key stakeholders once approval has been obtained.

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Section 10 - Responsibilities

(74) The Responsible Executive is responsible for:

  1. ensuring sufficient resources are allocated to ensure timely and effective review of University Policy documents.

(75) The Policy Owner is responsible for:

  1. identifying and being familiar with the University Strategic Plan, and legislation or University Policy documents that are relevant to or associated with the policy document;
  2. agreeing upon a final draft of the Policy document;
  3. ensuring that any communication and implementation actions to operationalise a policy document are developed and implemented;
  4. monitoring the appropriateness and effectiveness of their policy documents;
  5. maintaining a Policy Issues Register to record any issues associated with the relevant policy and reviewing this register to inform policy reviews;
  6. communicating rescission of a policy document to all key stakeholders once approval has been obtained.

(76) The Policy Author is responsible for:

  1. identifying and being familiar with the University Strategic Plan, and legislation or University Policy documents that are relevant to or associated with a policy document;
  2. identifying stakeholders relevant to the Policy document and undertaking sufficient and appropriate consultation to inform the policy drafting or review;
  3. drafting the Policy document;
  4. agreeing upon a final draft of the Policy document in consultation with the Policy Owner and submitting this to the Policy and Delegations Officer for quality review; 
  5. considering all recommendations made by the Policy and Delegations Officer that result from the quality review undertaken;
  6. maintaining records of consultation and submitting a summary of this consultation with the draft document when being submitted for approval;
  7. liaising with the Policy and Delegations Officer to confirm the correct approval pathway; and
  8. preparing the Cover Paper for submission of the draft policy document for approval, including all required appendices, and submitting the final policy document for approval.

(77) The Policy and Delegations Officer is responsible for:

  1. providing support and assistance to Policy Owners and Policy Author’s to ensure timely development and review of Policy documents;
  2. administration of the Policy Library, including publication of editorial and minor amendments (where approved if necessary);
  3. publishing and rescinding policy documents, where approved;
  4. providing timely notification to Responsible Executives of policy documents falling due for review; and
  5. undertaking quality reviews of draft policy documents and providing recommendations to Policy Owners for improvement.