Office of Regulatory Affairs and Compliance, Compliance Office 210-567-2014, ComplianceLine 1-877-507-7317

Standards of Conduct


UT Health San Antonio has the expectation of each employee to conduct all activities in compliance with all applicable laws and regulations and with the utmost ethical integrity. While the information which follows in this section is not all inclusive, it is indicative of important and frequent activities involving UT Health San Antonio employees in our daily business and workplace operations and offers answers to some common questions and situations.

It is important that all employees become familiar with this information. To ensure the comprehensiveness of the Institutional Compliance Program, new employees will acknowledge they have read, understood, and will comply with the terms of the Institutional Compliance Program and Standards of Conduct. This will be provided as part of the New Employee Orientation. Additionally, the Standards of Conduct will be distributed to all employees on an annual basis and anytime there are significant changes.

Access to Facilities and Services

UT Health San Antonio is committed to complying with the provisions of the Americans with Disabilities Act and providing equal employment opportunities and equal access to all UT Health San Antonio facilities and services for those with disabilities.

Accuracy of Records

All records, whether of a medical, operational, or financial nature, must be maintained in accordance with applicable laws and policies. No one may alter or falsify information on any record or document. Making any false statement in a medical record that is used to support billing of medical services may be considered criminal fraud. Billings to third-party payors (government and private insurance) and federal sponsored research are examples of records that must be accurate and conform to appropriate laws and regulations.

Audit Notification

The Office of Internal Audit & Consulting Services coordinates all financial audit activities at the University, including external audits. The Office of Internal Audit & Consulting Services is responsible for ensuring proper access to appropriate records and information. Any time notification is received that an external agency will be conducting a financial audit at the University, the Office of Internal Audit & Consulting Services must be informed.

Clinical Practice Compliance

UT Health San Antonio physicians are committed to providing high-quality patient care and to complying with all applicable laws and regulations. As a partner in a teaching hospital and as an academic medical center, the University intends to foster a teaching environment by educating physicians and other employees about the laws and regulations related to providing health care and billing for services to patients and third-party payors. Employees and medical staff members are subject to disciplinary action for failure to abide by the Standards of Conduct or the Faculty Practice Compliance Plans.

All claims for reimbursement made by or on behalf of the University’s physicians shall adhere to applicable laws, regulations, and policies. The institution will follow all legal and regulatory guidelines for billing physician services. The University shall collect only those amounts to which the institution is entitled, and promptly refund amounts billed and/or collected in error.

Communications with Elected Officials

The Office of Governmental Relations has the primary official responsibility to communicate with all local, state and federally-elected officials and their respective staff regarding UT Health San Antonio’s present and future legislative funding and policy priorities. In addition, state law and University policy prohibit employees from representing the University and as such expressing opinions for or against any legislative action on matters relating to official University business, or use any University resources, including stationery, fax machines, e-mails and telephones to conduct such activities.

Computer Information Security

It is a violation of the Texas Penal Code to disclose computer passwords; penalties range from a Class B misdemeanor to a felony depending on the related monetary damage. Computer passwords should be considered highly confidential. Never disclose computer passwords to anyone. Furthermore, do not write or otherwise document passwords in a place that is accessible by others.

Computer Software

Employees who use software licensed to the University must abide by applicable software license agreements and may copy licensed software only as permitted by the license. Unauthorized duplication of copyrighted software is a violation of federal copyright law. Furthermore, it is illegal to install licensed software on more than one computer, unless the license expressly provides for more than one installation. Employees should direct any questions about applicable software license agreements to their supervisor or call Computing Resources.

Confidential Information

Confidential information about the University’s students, employees, patients, strategies, and operations is a valuable asset. Although an employee may use confidential information to perform a job, that information must not be shared with others, inside or outside of the University, unless the individuals have a legitimate need to know and is shared in compliance with applicable laws, regulations, policies, and procedures. Confidential information includes personnel data, student information, patient information, research data, financial data, strategic plans, marketing strategies, employee lists and data, supplier and subcontractor information, and proprietary computer software. When the University collects information from individuals, such as students and patients, it is required to disclose to the individual their rights under federal regulations.

Conflicts of Interest and Commitment

University employees are prohibited from having a direct or indirect interest, financial or otherwise, in a corporation or business, engage in a professional activity, or incur an obligation of any nature that is in substantial conflict with or might reasonably tend to influence the discharge of the employee’s official duties at the University. All employees are expected to disclose annually, any financial arrangement with a company or entity external to the University that might create a potential conflict of interest and commitment. Special consideration should
be given to any conflicts that may affect research and clinical activities. Refer to The University of Texas System’s Ethics Policy below.

Conflicts of Interest and Commitment

The University expects to cooperate in government investigations with all reasonable demands made in any government investigation of a UT Health San Antonio or a University employee. However, it is essential that the legal rights of the University and its employees be protected. If an employee receives a subpoena, inquiry, or other legal document from any governmental agency regarding University business, whether at home or in the workplace, immediately notify the Office of Legal Affairs. The University does not prohibit an employee from speaking to any government investigator or agent. However, to best protect the employee and University, if any governmental agency or any attorney contacts an employee at home concerning UT Health San Antonio business, the employee may politely ask the agent to contact the employee at the office.

Contacts with the Media

The Office of Communications acts as the spokesperson for the University. If at any time a reporter is requesting information or is on the University campus, the employee should call the Office of Communications. If any member of the media contacts an employee, kindly instruct them to contact the Office of Communications. An Office of Communications representative is available after hours by pager to assist with media calls. Call UT Police after hours to page the Office of Communications.

Contracts and Agreements

Only individuals expressly authorized in writing by the President may enter into contracts or agreements, either orally or written, on behalf of UT Health San Antonio. No person may sign a contract unless expressly authorized to do so in writing by the President.

Criminal Background Check Requirements for Employees

A criminal background check will be conducted on:

  • A current employee who is a finalist for a posted position;
  • An intern, volunteer, and student in programs with assignments in clinical healthcare; or
  • A current employee when the President, or his or her designee, determines it is necessary to further the goals of the institution.

Self-Reporting: UT Health San Antonio faculty and staff must report to the Vice President and Chief Human Resources Officer in writing, within five (5) business days, any criminal complaint, information, indictment, no contest plea, guilty plea, or criminal convictions (and whether registered as a sex offender or will be required to register as a sex offender), excluding misdemeanor offenses punishable by fine. Subject to standard grievance and disciplinary procedures as applicable, failure to report is a violation of policy and may lead to disciplinary action as appropriate.
For more information, see the Handbook of Operating Procedures, Section 4.4.1, “Criminal Background Checks”.

Drug-free Workplace

UT Health San Antonio is committed to a drug-free environment. Faculty and staff reporting to work under the influence of an illegal controlled substance or alcohol, or unlawful manufacture, sale, distribution, dispensing, possession or use of a controlled substance is prohibited in the workplace and on any property under the control of the University. The use of alcoholic beverages is prohibited in and on University facilities. However, the President may waive this prohibition with respect to any event sponsored by the University.

Faculty and staff are required to notify the Vice President and Chief Human Resources Officer within five (5) calendar days of a conviction for an offense involving a controlled substance that occurred in or on the premises controlled by the University.

Any employee should report anyone who may be possessing, using, or selling alcohol or illegal drugs to UT Police at (210) 567-8911.

Dual Employment

Permanent full-time or part-time employees must receive permission from their home department and Human Resources before accepting a job assignment with another University, State of Texas agency, or with any vendor who provides services to the University. All payments to employees are subject to withholding and employment taxes. If they are currently employed full-time or part-time with another University, State of Texas Agency, or with any vendor who provides services to the University when accepting an offer from UT Health San Antonio, this employment must be disclosed to the hiring home department and Human Resources prior to accepting employment and date of hire. Please also reference the section on “Outside Employment.”

Environmental Hazards

It is the policy of the University to comply with all environmental laws and regulations pertaining to its operations. The University operates each of its facilities with the necessary permits, approvals, and controls. The University acts to preserve natural resources to the extent reasonably possible. UT Health San Antonio strives to employ the proper procedures with respect to handling and disposal of hazardous and waste, including but not limited to medical waste. The University makes reasonable efforts to minimize waste generated as a result of University activities. Appropriate receptacles must be used for the disposal of sharps, glass, and biohazardous waste.

The University is not subject to Federal Occupational Health and Safety Administration (OSHA) guidelines; however, the UT Health San Antonio is required to follow state laws and regulations, specifically the Texas Hazard Communication Act.

Equal Employment Opportunity

The University is an Equal Employment Opportunity/Affirmative Action employer. In the administration of its employment policies and practices, the University does not discriminate against employees or applicants for employment because of race, color, national origin, sex, sexual orientation, religion, age, veteran status, or disability. The University takes affirmative steps to ensure that applicants are hired, and employees are treated, in a non-discriminatory manner. The University’s commitment to equal opportunity principles applies to all aspects of employment, including recruitment, retention, promotion, compensation, benefits, and training.

Fair Labor Standards Act

The Federal Fair Labor Standards Act (FLSA) requires accurate time and leave records for all non-exempt employees at the University to be maintained. The University compensates non-exempt employees for hours actually worked in a one week over forty (40) hours. Employees must specifically obtain prior approval for overtime, compensatory, and equivalent time before it is worked. For detailed information regarding overtime contact Human Resources.

Family and Medical Leave Act

If an employee satisfies the eligibility criteria, the employee may request and receive a leave of absence without pay for up to twelve (12) weeks per year for certain family and medical reasons. Contact Human Resources for eligibility criteria.

Fraud, Waste, and Abuse

It is every employee’s responsibility to prevent fraud, waste, and abuse. The University of Texas System Fraud Policy specifies individual responsibilities and actions regarding fraud/dishonest acts.

  • Fraud is defined as knowingly and willfully attempting to receive financial gain by making false statements or developing a scheme to receive anything of value.
  • Abuse is defined as activities that result in excessive or unreasonable costs to the University, or other state or federal agencies.

Employees who are discovered in any type of fraud or abuse activity will receive disciplinary action, including termination and possible prosecution, if applicable.

Gifts and Gratuities

An employee must not accept or solicit any gift, favor, or service that might reasonably tend to influence the discharge of official duties or that the employee knows or should know is being offered with the intent to influence official conduct.


An employee must not solicit, accept, or agree to accept an honorarium in consideration for services that the employee should not have been requested to provide but for the employee’s official position or duties.

Intellectual Property

Intellectual property includes any invention, discovery, trade secret, technology, creation, scientific or technological development, computer software, or other form of expression of an idea that arises from the activities of persons employed by the University, anyone using UT Health San Antonio facilities under the supervision of University personnel, or candidates for master or doctoral degrees. The University of Texas System Board of Regents owns the intellectual property created by its students and employees if the intellectual property is:

  • created by an employee within the scope of employment;
  • created by an employee on UT Health San Antonio with the use of University facilities or state financial support;
  • commissioned by UT Health San Antonio or The University of Texas System pursuant to a signed contract;
  • fits within one of the nine categories of works considered works for hire under copyright law; or,
  • results from research supported by federal funds or third-party sponsorship.

A University employee must disclose the intellectual property created by the employee to UT Health San Antonio well before the employee submits any information about the intellectual property for publication or makes any public disclosure or even a private disclosure to a commercial entity.
Any involvement in the theft of intellectual property by an employee will result in disciplinary action, including termination and possible referral for prosecution.

The Board of Regents of the University of Texas System own all data and commercially valuable information created while an individual is employed by the University, whether or not it is subject to patent protection or software copyright. See Regents Rule 90101: Intellectual Property. Any transfer, attempted transfer or diversion of this intellectual property to third parties, including other countries, is expressly forbidden and will be considered theft of State of Texas property. Penalties include disciplinary action that may include termination and possible referral for criminal prosecution.

Interactions Between Clinicians and Researchers with Industry

The University has implemented a set of policies and procedures aimed at reducing the influence of pharmaceutical industry and device manufacturers on educational content and clinical decision making, as well as setting strong ethical and procedural standards for interactions between faculty and industry. These policies ban our faculty from accepting gifts which includes pens, pads, other small gifts and meals. The policy also significantly restricts the presence of industry representatives in clinical and teaching areas of UT Health San Antonio. See Section 10.1.11 “Guidelines for Interactions Between Clinicians and Researchers With Industry”, of the Handbook of Operating Procedures.


Kickbacks are undisclosed payments, gifts, or services offered in return for something of value, increased business, or business referral. It is a criminal offense to receive or solicit any remuneration, including a gift, cash, bribe, rebate, or discount in return for referring an individual or patient to the University or for any service offered by UT Health San Antonio. It is also a crime to receive or solicit remuneration in return for purchasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good or service. Employees who are involved in any type of kickback scheme will receive disciplinary action, including termination and possible prosecution, if applicable.

Outside Employment

The first responsibility of the faculty and staff is to the University; outside professional commitments should not interfere with a faculty or staff member’s responsibility to the University. There are numerous regulations governing outside employment. They cover paid employment and volunteer service, such as with a not-for-profit organization or other governmental entity. Generally, these regulations prohibit employees from outside employment that would cause a conflict of interest and commitment, reduce the ability to perform the University job, or bring discredit to UT Health San Antonio. If an employee is considering any form of outside employment or currently hold outside employment, the employee should contact the department administrator and notify Human Resources to determine the regulations that apply to the particular situation.

Full-time employees must receive permission from the University before accepting employment or independent contractor status of any type from another State of Texas agency or any vendor who provides services to the University. The President’s Office will determine whether this possible employment might create a conflict of interest situation for the employee or UT Health San Antonio.

Photocopying of Copyrighted Material

Most works should be presumed to be copyright protected, unless further information from the copyright holder or express notice reveals that the copyright holder intends the work to be in the public domain. Permission must be obtained from the copyright owner to copy copyrighted materials where: copying extends beyond the boundaries of the guidelines contained in the copyrighted materials policy; advice of The University of Texas System’s Office of General Counsel has not been sought; and, copying is not fair use.

Political Activities

An employee may participate in political activities provided such activities:

  • are not conducted during work hours;
  • are in compliance with the constitution and laws of the State of Texas;
  • do not interfere with the discharge and performance of the employee’s duties and responsibilities;
  • do not involve the use of equipment, supplies, or services of the University;
  • do not involve the attempt to coerce students, faculty, or staff to participate in or support the political activity; and,
  • do not involve the University in partisan politics.

In addition, employees are not allowed to support or oppose (in writing or orally) legislation as UT Health San Antonio employees.

Political Contributions

Political contributions from any source of University funds are prohibited.

Property Loss

When institutional property disappears, whether through theft or other cause, as a result of an employee failing to exercise reasonable care for its safekeeping, such person shall be liable for the loss sustained by the institution.

Purchases for Items, Goods, or Services

No employee may expend University funds for any purchase unless the person is authorized to make the purchase, and the purchase is made in accordance with all institutional purchasing procedures. University employees should aid in achieving the current Historically Underutilized Business (HUB) purchasing goals.

Research Integrity

One of the University’s goals is to create a scientific community that adheres to high ethical standards while conducting research, as well as to promote creativity in scientists and academicians. The University believes that this can be accomplished by promoting integrity on research projects where every investigator maintains permanent auditable records of all experimental protocols, data, and findings. The University will not tolerate intentional research misconduct. Faculty and employees applying for and conducting research of any type are responsible for complying with all applicable laws and regulations.

When requesting reimbursement, the policy is to submit only true, accurate, and allowable costs that are appropriately related to each individual research grant or contract. Principal Investigators are responsible for ensuring that costs charged to their individual grants and contracts comply with the applicable costing regulations and conditions of each grant.

Retention and Disposal of Records

The University is required to maintain an active and continuing records management program that identifies vital and confidential records and ensures the appropriate retention and disposition of records. No employee should tamper with records or remove or destroy them except in accordance with the approved retention and disposition policy.

Sexual Harassment and Sexual Misconduct

The University is committed to the principle that the working environment should be free from inappropriate conduct of a sexual nature. Sexual harassment and sexual misconduct are illegal and unprofessional. Employees who engage in such conduct will be subject to disciplinary action, including termination.

Time Keeping

All employees eligible to earn vacation and sick leave must report vacation and sick leave taken in accordance with University procedures. Employees must maintain complete records of worked time and specific leave records to account for hours worked, vacation, sick and personal leave, compensatory, and equivalent time balances.

Use of State-owned Property

It is the responsibility of each employee to preserve the University’s assets, including time, materials, supplies, equipment, and information. Institutional assets must be used only for state purposes. As a general rule, the personal use of any University asset is prohibited. The incidental use of items such as e-mail, the Internet, and telephones is permissible provided that the use complies with all applicable policies and that the use does not result in additional cost to the University. A local phone call is an example. Any use of University resources for personal financial gain is prohibited. Telephone logs and e-mail are public property andmay be subject to open information requests.

Weapon-free Workplace

Generally, weapons are prohibited on campus; however, the University has designated places on campus where concealed carry is permitted when in compliance with the Campus Carry policy.

An employee should report anyone who may be in possession of an illegal weapon to UT Police at (210) 567-8911.

Workplace Health and Safety

All University employees must perform their duties in compliance with all applicable institutional policies, federal, state and local laws and standards relating to the environment and protection of worker health and safety. Employees should become familiar with and understand how these laws, standards, and policies apply to their specific job responsibilities. Employees should seek advice from their supervisor or the Environmental Health and Safety Office, as needed. Each employee is responsible for advising the employee’s supervisor or the Environmental Health and Safety

Office of any serious workplace injury or any situation presenting a danger of injury so that timely corrective action may be taken. Supervisors must report unsafe practices or conditions to the Environmental Health and Safety Office.

Workplace Violence

The University strives to assure that employees are provided a safe working environment. Violence in the workplace is not tolerated at UT Health San Antonio. Workplace violence may be considered illegal and it is certainly unprofessional. Employees, who are involved in violent actions against other individuals or verbal or written threats directed at individuals, will be subject to disciplinary action up to and including termination.
Employees who observe or experience any form of harassment or discrimination should report the incident to their supervisor, and/or Human Resources, or the Compliance Line (1-877-507-7317).

Employees who are made aware of, observe, or experience sexual misconduct, including but not limited to sexual harassment or assault should immediately report any information to the Title IX Director, or to UT Police.
Incidences of violence should be reported immediately to UT Police at 911.

The University of Texas System’s Ethics Policy

The University of Texas System’s Ethics Policy is as follows:
Officers, faculty, and employees (collectively “employees”) of The University of Texas System may not have a direct or indirect interest, financial or otherwise, that is in conflict with the proper discharge of their duties. Potential conflicts of interest must be disclosed.
Employees shall adhere to the applicable laws, rules, regulations, and policies of governmental and institutional authorities. The failure to do so will be grounds for disciplinary action, up to and including termination of employment.

  • No employee shall accept or solicit any gift, favor, or service that might reasonably appear to influence the employee in the discharge of duties.
  • No employee shall disclose confidential information or use such information for his or her personal benefit.
  • No employee shall transact any business in an official capacity with any business entity of which the employee is an officer, agent, or member, or in which the employee owns a substantial interest.
  • No employee shall make personal investments that could reasonably be expected to create a conflict between the employee’s private interest and the public interest.
  • No employee shall accept other outside or dual employment or compensation that could reasonably be expected to impair the employee’s independence of judgment in the performance of the employee’s public duties.
  • Sexual misconduct and sexual harassment are unacceptable behaviors. Such unacceptable behavior includes verbal or physical conduct of a sexual nature. Incidents of sexual misconduct or sexual harassment should be reported to the office charged with reviewing such complaints where the incident occurred.

The State of Texas and The University of Texas System have defined numerous ethical standards that apply to each employee. The most complete and current source of information on ethical standards is The University of Texas System Office of General Counsel (OGC) web page.

Ethical behavior is expected of every employee of The University of Texas System. Each employee has a personal obligation to report any activity that appears to violate such laws, policies, rules and regulations.

The University of Texas System’s Statement of Values and Expectation

The University of Texas Systems Values and Expectations are as follows:

All UT System officers and employees must ensure that the University of Texas System maintains its reputation as a System that strongly values integrity and requires all operations to be conducted with accountability, transparency, and respect.

Employees are expected to comply with all applicable federal, State, and local laws as well as applicable rule and policies. There are minimum expectations to be followed.

  • Trust and Credibility. Trust and confidence are gained by adhering to commitments, displaying honesty and integrity, and reaching goals solely through diligence and honorable conduct.
  • Respect for the Individual. All employees are treated with dignity and respect.
  • Culture of Open and Honest Communication. Managers have a responsibility to create an open and supportive environment where employees understand the importance and value of raising and responding to concerns about potentially questionable or unethical behavior.
  • Setting the Tone. UT System leadership will demonstrate through actions and leadership by being responsible for promptly and appropriately reviewing questions or concerns about ethical behavior raised by employees or others and for taking appropriate and timely steps to address any problems identified.

False Claims Act

The False Claims Act (FCA) was passed by Congress to prevent the United States Government from paying federal funds for fraudulent claims involving goods and services. For UT Health San Antonio, this includes a person who presents a false claim to a government employee or who provides a false record to get a claim paid or approved by the United States Government. The FCA outlines the federal penalties for submitting false claims, as well as protections granted to an individual who reports a violation.

Any employee who is fired, demoted, suspended, harassed or otherwise discriminated against by his or her employer because of a claim, lawfully filed by the employee, is protected by the federal government and will be entitled to reinstatement, back pay and compensation for damages resulting from the discrimination.

The penalty for making a false claim is a fine no less than $5,000 and not more than $10,000 plus three times the amount of damages to the government.

For more information, contact the Office of Regulatory Affairs & Compliance at (210) 567-2014 or the Office of Internal Audit & Consulting Services at (210) 567-2370.

Texas State Law on Whistleblower Protection

University employees are protected by the Texas State law from retaliation for reporting a violation of law to government entities. The law states:

  • The University may not suspend, terminate or threaten an employee for reporting a violation to a law enforcement authority. The University may be held liable for any form of retaliation taken against an employee, student or volunteer who reports fraudulent activity.
  • A University employee who is suspended or terminated or has been threatened for reporting a violation is entitled to sue for injunctive relief, actual damages, court costs and reasonable attorney fees. In addition, the employee is entitled to return to the same or an equal position and to payment of lost wages.
  • An employee suing the University may not recover damages in an amount that exceeds $250,000.
  • An employee must sue within 90 days of the alleged suspension, termination or threats. The suit must be filed in the district court of the county in which the retaliation took place or in a district court of Travis County.
  • A supervisor who suspends, terminates or makes threats against an employee for reporting a violation to a law enforcement authority can receive a civil penalty up to $15,000.

For more information, see the Handbook of Operating Procedures, Section 2.5.2, “Protection from Retaliation for Reporting Suspected Wrongdoing”.