School of Nursing: Policy on Faculty Compliance


School of Nursing: Policy on Faculty Compliance

Unit Policy



Employment at the University is contingent upon faculty meeting and maintaining essential compliance requirements. In addition, the many clinical agencies with whom UNC School of Nursing (SON) faculty engage as part of their teaching, research, or service mission(s) have policies that must be adhered to as per contractual agreement. These clinical site requirements are in addition to University employment-related policies. Clinical agency policies are subject to change often with little notice. The purpose of these policies is to both protect the faculty member as well as the public with whom the faculty member interacts as part of their work as a University employee.

Scope of Applicability

Faculty employed by the School must achieve compliance with all health, safety, and legal requirements at the time of hire and prior to any contact with students, clients, or research subjects. Continuing faculty must maintain full compliance with all renewable requirements throughout their tenure with the School. Faculty adherence to these compliance requirements is expected regardless of the type of teaching, practice, service, or research assignment in any particular term. All faculty who enter any clinical facility on a regular basis in their role as a UNC SON faculty member regardless of the role in which they are engaging at the time (teaching, research, service) must adhere to that agency’s compliance requirements.


Policy Statement

Compliance requirements are ever-evolving and expanding. They include initial employment related requirements as well as recurring employment related requirements that require regular monitoring. For example, they range from holding a valid and current RN license to practice in the state of North Carolina to policies related to infections/communicable diseases that may be a threat to those with whom the faculty member comes into contact. For a list of current Faculty Compliance Requirements, see the "Passport - Faculty Check List Form" page on the Wake Area Health Education Center (AHEC) website.

Additional, supplementary requirements may be contractually mandated by a clinical agency where a faculty is practicing, supervising students, engaging in service, or conducting research. These additional elements are required and non-negotiable.

Any faculty member who fails to attain full compliance during their period of SON employment will not be allowed to assume or continue their academic responsibilities. Faculty who fail to maintain currency of all requirements will be removed from all clinical agency, client/subject, and student contact. Failure to maintain full compliance or tardiness in meeting requirements will be reported to the SON Associate Dean for Academic Affairs for action, and will result in a ‘Does Not Meet Expectations’ on their annual evaluation, meaning the faculty will be ineligible for merit considerations in the year in which the lapse occurred.

Ensuring Faculty Health

Infectious/communicable diseases are common and may be a threat to SON faculty. During the performance of clinical practice/research activities, faculty may have contact with patients/subjects with various infections such as bloodborne transmitted disease (e.g., Hepatitis B [HBV], Hepatitis C [HCV], Human immuno-deficiency virus [HIV; AIDS]), airborne transmitted disease (e.g., tuberculosis [TB], measles, varicella), droplet transmitted disease (e.g., influenza, pertussis, mumps) and contract transmitted disease (e.g., methicillin-resistant Staphylococcus aureus). This contact may expose the faculty member to infectious agents and may result in transmitting an infectious disease to others. During pregnancy, the fetus may also be at risk depending on the infection (e.g., varicella).

To help protect the health and safety for all, the School of Nursing requires:

  1. Initial infectious disease screening
  2. Pre-exposure prophylactic immunization against specified infectious/communicable diseases
  3. Post-exposure prophylactic follow-up/treatment following exposure to specified infectious diseases such as HBV, HIV, and tuberculosis

Compliance Repositories

The School of Nursing is required to use the University Employee Occupational Health Clinic (UEOHC) for faculty compliance monitoring and tracking. UEOHC will also maintain HIPAA, licensure and certification data, and CPR training status.

Non-health related, agency-specific compliance documents will be housed in an online vendor database. Each faculty member will have their own account, funded by the SON, where documents will be stored.

Use of these two repositories will facilitate review and monitoring as well as allow for timely response when an agency audits for faculty compliance.

Faculty Responsibilities

Faculty are responsible annually for reviewing the status of their employment and health requirements via the UEOHC portal. Faculty are responsible for ensuring all immunizations are current and that verification of immunization, HIPAA training, and CPR cards is available in the UEOHC portal. Faculty who are nurses are required to maintain their RN License in the UEHOC database. Attestation of meeting these requirements is no longer permitted.

Faculty will be accountable for completing all clinical agency-required documents housed in the online vendor site. The vendor will not be reviewing these documents for accuracy or completion. Faculty must have completed all required training by deadlines to avoid jeopardizing student learning.

Upon hire or upon assignment to teach a clinical component of a course the Academic Associate Dean or hiring individual will notify SON Human Resources (HR) whether or not surveillance via the UEOHC is required based on job responsibilities. In turn, SON HR will ensure notification to the UEOHC system. The faculty member will be informed of their specific clinical agency assignment by the course coordinator. Faculty are responsible for meeting all clinical agency training, compliance, and competency requirements prior to the start of any clinical rotation or prior to any regular engagements in a health care facility. Additionally, clinical agencies may require other documents to be completed in addition to clinical competency requirements. These agency specific required documents must be completed prior to each semester and will be found in the online vendor’s site. Failure to maintain currency will result in disciplinary action. There is no grace period following an expiration date. It is the sole responsibility of each faculty to maintain a current knowledge of their compliance standing. The faculty member is reminded to maintain a personal file of all compliance-related documents and certificates.

Faculty who teach in the Undergraduate program are required to have a current North Carolina Board of Nursing (NCBON) Curriculum Vitae (CV) on file at the Board. See the "Faculty Vitae Form" link under "Education Forms" on the NCBON website for details on that CV format. Faculty are required to maintain their own NCBON CV and to provide the AssociateDean/Undergraduate Division and Program with a current version. These CVs are stored in the faculty personnel files in the SON HR Office.

School of Nursing Responsibilities

The School provides the necessary information to faculty for achieving and maintaining compliance via a secure, PID authenticated database that is accessible on the Web. The UEOHC database is designed to enable faculty to meet the health-related compliance requirements for the School/University as well as all clinical agencies. The School also contracts with an online vendor to ensure that faculty have a web-based solution to agency-specific compliance documents.

The Office of Administrative Services (OAS) has primary responsibility for obtaining initial and continuing employment related documents, such as employment criminal background check and verification of RN license (if applicable). Faculty who do not meet these initial or continuing requirements will be reported by OAS to the Associate Dean for Academic Affairs and the appropriate Academic Assistant Dean.

For supplemental requirements, the Office of Academic Affairs (OAA)/Clinical Support Division has primary responsibility for obtaining and maintaining information regarding clinical agency requirements in the online vendor’s site. The course coordinator will direct clinical faculty to this online vendor the semester prior to the implementation of the course as part of the planning process. This must be completed prior to the start of the semester in which the course is being offered.

The School is a member of the Consortium for Clinical Education and Practice Consortium (CCEP) of Wake AHEC. The CCEP identifies, prioritizes, and addresses clinical placement issues for nursing students in the Triangle Region of North Carolina. The SON adheres to all CCEP standards and policies. The School is required to notify all faculty and students when there are changes to CCEP policies and policies of other clinical agencies with whom the SON has a contractual affiliation agreement. This will occur via email notification.

Employment Required Health and Safety Requirements

  • Personal health/accident insurance coverage.
  • Background check based on legal name, date of birth and employee provided SSN and covering the lesser period of the past seven years to include a search of:
    • all geographic addresses, both domestically and internationally, associated with the faculty member’s complete residential history, places of employment, and educational institutions the faculty has attended in the past seven years;
    • all felony and misdemeanor charges and convictions (except minor traffic related violations);
    • a national Sexual Offender/Predator Database check; and
    • a check against the Office of the Inspector General's List of Excluded Individuals/Entities (LEIE) and the General Services Administration's Excluded Parties list (EPLS).

Continuing Compliance Requirements

ALL documentation must be submitted for official review through UEHOC.

Compliance-Related Health Requirements

Compliance-Related Safety Requirements

  • AHA-BLS Certification or PALS, renewal required every two years
  • Annual OSHA training/testing: required modules: blood and air-borne pathogens, tuberculosis and infection control, and JCAHO general safety

Related Requirements

Compliance-Related legal requirements

  • SON Confidentiality Statement*
  • Annual HIPAA training/testing: general privacy module only
  • Unrestricted RN License (if applicable)
  • AHEC Core Orientation

Related University/School of Nursing Policy documents

Contact Information

Policy Contact

Peggy Wilmoth, Executive Vice Dean/Associate Dean Academic Affairs

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Article ID: 132373
Thu 4/8/21 9:29 PM
Mon 3/4/24 11:42 AM
Responsible Unit
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School of Nursing
Issuing Officer
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Senior Associate Dean for Academic Affairs
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02/23/2024 12:00 AM
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02/23/2021 10:01 AM
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02/23/2021 10:01 AM
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02/23/2021 10:01 AM
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02/23/2021 10:01 AM