HomeMy WebLinkAboutPolicy and SOP Management - SOPIdaho
Department of
Correction
Standard
Operating
Procedure
Title:
Policy and Standard Operating Procedure
Management
Page:
1 of 15
Control Number:
103.00.01.003
Version:
3.0
Adopted:
04-06-2012
Josh Tewalt, administrator of budget and policy, approved this document on 02/28/2017.
Open to the public: Yes
SCOPE
This standard operating procedure (SOP) applies to all staff members involved with the
process of developing, revising, reviewing, writing, and approving of manuals, forms, SOPs,
and policies.
Revision Summary
Revision date (02/28/2017) version 3.0: This document was revised in its entirety.
TABLE OF CONTENTS
Standard Procedures ................................................................................................................ 2
Board of Correction IDAPA Rule Number ................................................................................ 2
Policy Control Number 103 ....................................................................................................... 2
Purpose ..................................................................................................................................... 2
Responsibility ............................................................................................................................ 2
Standard Procedures ................................................................................................................ 3
1. Overview ............................................................................................................................... 3
2. Controlled Document Management ...................................................................................... 3
3. Document Standards ............................................................................................................ 4
4. Legal Review and Approval .................................................................................................. 4
5. Disclos ure ............................................................................................................................. 4
6. Editing Levels and Methods ................................................................................................. 5
7. Common Errors..................................................................................................................... 6
8. Process Steps ....................................................................................................................... 8
9. Links and Hyper Links .......................................................................................................... 9
10. Definitions ........................................................................................................................... 9
11. Requesting a Document for Revision or Development ...................................................... 9
12. Development or Revision Process ................................................................................... 10
13. Information for Authors ..................................................................................................... 11
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14. Final Review and Publishing Process .............................................................................. 12
15. Review Time Limits ........................................................................................................... 14
16. Publishing Process ........................................................................................................... 14
Definitions ............................................................................................................................... 15
References .............................................................................................................................. 15
STANDARD PROCEDURES
BOARD OF CORRECTION IDAPA RULE NUMBER
None
POLICY CONTROL NUMBER 103
Rules and Policy Management
PURPOSE
The purpose of this standard operation procedure (SOP) is to establish procedures for
writing, revising, and publishing manuals, forms, standard operating procedures, and
policies. For the purpose of this SOP, manuals, forms, standard operating procedures, and
policies are referred to as controlled documents , unless referring to specific document types .
RESPONSIBILITY
Director or designee
The director or designee is responsible to ensure that IDOC administrators and
managers, referred to as approval authorities in this SOP, implement controlled
documents that support and direct the agency philosophy and vision in an efficient
manner.
Approval Authority or designee
Approval authorities or their designees are responsible for:
Setting priorities for the development and revision of controlled documents
Ensuring policies and SOPs for their divisions meet the current needs
Designating staff (authors) to write, update, or revise controlled documents
Ensuring that authors coordinate revisions with the policy coordinator
Reviewing and approving documents for their division
Deputy Attorneys General
The deputy attorneys general (DAG) are responsible for
Reviewing new or revised policies or SOPs, and if requested, forms and manuals, to
identify any content that may present a legal issue
Reviewing level of public disclosure of a policy or SOP, or its related form s or manual
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Policy Coordinator
The policy coordinator is responsible for:
Facilitating the drafting, revising, reviewing, and approving of controlled documents
Managing quality control of controlled documents
Managing document control of controlled documents
To the extent possible, ensuring that only approved or standardized terms and
definitions are used in controlled documents
When applicable, ensuring that policies and standard operating procedures are
compliant with IDAPA rules
Formatting and publishing controlled documents
Maintaining a permanent file of controlled documents in hard copy
Coordinating with approval authorities for the development of redacted versions for
restricted or partially restricted policies and SOPs
Ensuring that Word versions of controlled documents are only released to authorized
authors for revision or development
Authors
Using the guidelines in this SOP to improve docum ent quality and standardization
Consulting other divisions affected by a controlled document under revision or
development
Ensuring that division leadership makes and approves policy decisions contained in
controlled documents
Submitting, to the best of their ability, quality work to the policy coordinator
STANDARD PROCEDURES
1. Overview
Controlled documents enable IDOC staff members to work in a safe, efficient, and lawful
manner consistent with department philosophy. Staff members responsible for the
development and revision of controlled documents must ensure that the process is efficient
and timely. The department goal is to publish quality, user -friendly documents in a timely
manner.
2. Controlled Document Management
The policy coordinator is responsible for the management of controlled documents.
Electronic versions of controlled documents are maintained in a limited access file named
Doc Management Library. Access to the Doc Management Library is limited to the following:
The polic y coordinator
Policy coordinator supervisor
Policy management staff
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The budget and policy administrator may approve additional access on an individual basis.
3. Document Standards
Staff members involved in writing and revising controlled documents are responsible for
quality control. The policy coordinator is responsible to ensure that controlled documents
substantially meet IDOC writing standards and formatting. However, the policy coordinator is
also responsible to ensure that the review , approval, and publication process is efficient.
Therefore, it is important that the pursuit of perfection does not stall or delay the process.
For example, an SOP may contain many passive sentences that require time to revise.
Although the goal is to us e active voice, revising an entire document only to reduce passive
voice is not an efficient practice. Authors and the policy coordinator should focus on
ensuring the document is clear enough that end users can understand it and then move
forward with publishing. Once published, m inor revisions can occur quickly should the
document need further clarification or correction.
Revision Numbering
Whole numbers are used for versions, for example 1.0, 2.0, 3.0. Version numbers , such
as 2.4 might be seen on older documents. The next version of an older document is a
whole number (3.0 follows 2.4). The policy coordinator and authors may use tenths such
as 3.1, 3.2, 3.3, etc. to track the progression of a document during the revision process.
4. Legal Review and Approval
Approval Authority
This section identifies the approval authority for each document type as follows:
The director or deputy director approves policies.
The division chief or equivalent approves standard operating procedures, forms, and
manuals that apply primarily to that division (the approval authority may designate
approval of forms and manuals).
The human resource manager approves human resource standard operating
procedures .
Legal Review
The DAG reviews documents for legal issues and the level of dis closure.
5. Disclosure
All IDOC policies and SOPs are available to the public and offenders, unless the policy or
SOP is exempt from disclosure in full or in part.
Open for Public Disclosure in Full
If a document is open for public disclosure in full, any of the following actions are
allowable:
Any IDOC employee or contract staff member may provide an offender, other
agenc y, or the public access to the document.
Any IDOC employee or contract staff mem ber may provide an offender or the public
a copy of the document.
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The public may download and/or print a copy from a non-IDOC computer.
Open for Public Disclosure in Part
The IDOC policy coordinator must restrict controlled documents that are exempt from
public disclosure in part when publishing on the IDOC website. If a document is exempt
from public disclosure in part, the IDOC’s policy coordinator must obtain a redacted
version approved by the document’s approval authority. The policy coordinator, at the
approval authority’s request, may help in the redaction process. The policy coordinator
maintains redacted documents in the document library. The policy coordinator, or
designee with approved access to the document library, is authorized to provide
redacted documents to offenders and the public.
Exempt from Disclosure:
The IDOC policy coordinator must restrict controlled documents that are exempt from
public disclosure when publishing on the IDOC website. If a document is exempt from
disclosure, it must not be released in any form to an offender, another agency, or the
public.
6. Editing Levels and Methods
The policy coordinator uses the following levels of editing:
Formatting
Administrative Editing
Editing
Integrity is crucial in the document control process. Transparency is vital to ensure the
content is not altered without the knowledge of the approval authority. To ensure
transparency, the following standards are used:
Formatting
The policy coordinator performs formatting, typically without using track changes.
Formatting does not include any change to the text, with the exception of moving a block
of text to another location in the document to meet current standards , such as moving
definitions from the beginning to the end of the document . Rearranging sections in the
body of the document is considered editing. Formatting does not require approval from
the approval authority; however, as a courtesy, the policy coordinator should provide the
approval authority or designee an opportunity to review the document before publishing.
Formatting includes the following actions:
Styles of headings, paragraphs, bullets, headers, and footers
Capitalization
Spaces following punctuation
Use of bold, italics, underline
Table of Contents
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Administrative Editing
Administrative editing includes minor word changes, grammar corrections, repairing or
removing hyperlinks, correcting spelling errors, and changes that do not alter the
meaning or are non-substantive. The policy coordinator and/or author can make
administrative changes without using the full revision process such as completing the
DAG review. Administrative changes should be done quickly. However, whenever text
is changed, the policy coordinator must use track changes and obtain approval of the
change from the approval authority or designee before publishing the revision.
Editing
Editing refers to any revisions that are beyond administrative editing. The policy
coordinator may choose to edit a document that does not meet current writing standards,
such as control word use (shall, or will, vs must, should, or may), converting passive
sentences to active sentences, etc. The policy coordinator must use good j udgment
when editing and strive to maintain the meaning of the original text. Extensive editing,
even when improvements are possible, is generally unnecessary and can delay the
process, increas e the risk of unintended content errors, and undermine the development
process of the division that owns the document.
When editing, the policy coordinator should consider the level of help the document
owner is requesting and conduct the editing in a manner intended to help author skill
improvement. For example, if a problem exists throughout a document, the policy
coordinator m ay correct a section or two and then return the document to the author for
further correction.
7. Common Errors
The policy coordinator is responsible to ensure that controlled documents substantially meet
department formatting and style guidelines. Authors can speed the process by avoiding
common errors that delay the process. Here are some common errors:
Capitalization:
Only proper nouns are capitalized. Do not capitalize divisions, job titles, team titles, or
the word department. Do not use ‘all caps’. The only words that use all capital letters are
“THE IDAHO DEPARMENT OF CORRECTION” in the header used on forms and
appendices. In section titles, capitalize each word, except small words such as the, and,
of.
Underline:
Do not use underline for any reason other than the limited use of hyperlinks.
Bold:
Use bold sparingly when emphasis is needed.
Double space:
Do not double space after periods . Double spacing was standard when typewriters
were used. However, computer programs have eliminated the need for this . Only use
single space after periods.
Pronouns:
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The IDOC adopted the Idaho Rule w riting guideline of using only male pronouns instead
of him/her. Use a male pronoun when the subject is singular. Use a female pronoun only
when referring specifically to the female gender. Do not use plural pronouns when the
subject is singular. In many situations, pronouns can be avoided with a carefully worded
sentence.
Formatting:
Controlled documents use about half a dozen styles for formatting: Heading 1, 2, 3, and
occasionally 4, normal indent, normal indent 3, and occasionally normal, list bullet 2 and
3. Authors, who are responsible for writing controlled documents on an ongoing basis,
must learn to use styles in Microsoft Word.
Do not attempt to make a document ‘look r ight’ using the space bar, tabs, etc.
Font
All IDOC controlled documents use a standard font, which is Arial 11pt. If necessary, a
smaller font size can be used on forms to make things fit.
Serial or Oxford Comma
A serial comma or series comma (also called Oxford comma and Harvard comma) is a
comma placed immediately before the coordinating conjunction (usually and/or) in a
series of three or more terms. A majority of style guides mandate use of the serial
comma, including APA style, The Chicago Manual of S tyle, The MLA Style Manual,
Strunk and White's Elements of Style, and the U.S. Government Printing Office Style
Manual. For example, “Team members are provided uniform boots, pants, and shirts.
The IDOC uses the serial comma to avoid confusion unless it wo uld alter the intended
meaning of the sentence.
Example: Form c opies are blue, yellow, and red: three separate pieces of paper each a
specific color.
Do not use a serial comma if it would alter the meaning, for example:
Form copies are blue, yellow and red: two pieces of paper, one blue the other yellow and
red.
Bullets and Numbered Lists
Use bullets to list items, terms, etc. when the list is three items or more. Use number list
when sequence or order of priority are required. Do not use semi colons and /or a
conjunction between the second to last and last item on a list. Do not use periods if the
phrase is not a complete sentence. Use parallel construction whenever possible to avoid
having a mix of complete and incomplete sentences in the same list.
Do not use bullets for paragraphs or statements that are comprised of two or more
sentences (occasionally a limited number of clauses in a list may contain more than one
complete sentence).
State Statues and Other References
Generally, do not cite state statues, IDAPA rules, and other legal, or government
documents in the body of a document; however, these may appear in the Reference
section. The author, policy coordinator, DAG, and review authority are responsible to
research state statues, IDAPA rules, and other requirements and ensure that the
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document is written in accordance with said rules and provides applicable guidance and
instruction to end users . Staff members should not be referred to a statute and asked to
determine how to apply it to their jobs. Avoid quoting statues. The document must
explain the requirement of the statute, act, or law in plain English. Keep the end user in
mind.
Note Boxes
The department no longer uses note boxes but they may still be seen in older
documents. When a document is revised, the note boxes are normally removed, unless
the revision is minor and the document owner does not want to delay publication while
doing reformatting.
Occasionally, a division may feel in necessary to have a highlighted box containing
important text that must stand. The text must represent a caution, warning, or reminder
and label the text with the applicable term. When using this technique, use a single row,
single column table. Do not use a text box.
Example:
Warning! Refusal to submit to a search will result in the loss of the inmate’s visiting
privileges!
8. Process Steps
Process steps prevent large dense paragraphs making procedures easier to read and
understand. Process steps describe a series of actions completed by more than one person.
W hen one person completes a series of tasks, use a bulleted or numbered list.
Process steps are written using a three-column table. When writing process steps, put the
responsible person’s title in the left hand column, the middle column is a numbered
sequence, and the third column states the action taken. Start the sentence in the action
taken section with either a verb or a qualifying statement.
Examples:
Send an email the facility head.
Or a qualifying phrase:
Before the end of shift, send an email the facility head.
Do not repeat the name of the responsible person in the action taken section. Do not
assign actions to a second party in the action taken section.
For example , do not write:
Before the end of the shift, send an email the facility head. The facility head must then
send an email the administrative duty officer.
Pass the responsibility to the next person. In the previous example, “email the facility head”
passed the responsibility. The facility head becomes the responsible person in the next step .
The first time a responsible person is identified, the person’s title is bold, and thereafter it is
not bold. When responsibility is passed to the next person, that person’s title is bold and if
that person has more than one-step, the title is not bold.
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When a responsible person completes several steps, it is permissible to merge the cells so
that the responsible person’s title appears once instead of repeated each step.
9. Links and Hyper Links
Use the following guidelines regarding links within documents and hyperlinks to web
addresses outside of documents.
Internal Links
The policy coordinator is responsible to ensure that the table of contents is updated
before publishing the document. The table of contents contains two levels: heading 1
and heading 2. The table is linked to the respective sections. Other internal links in the
document are not used such as link to a section. If a division feels an internal link is
critical, the policy coordinator can approve on an individual basis. Intern al references
can be used, such as , “see section 5,” when the divis ion feels it important to do so.
However, generally such references clutter the document, make reading more difficult,
and therefore, should be used sparingly.
Hyperlinks to External Documents and Webpages
Hyperlinks to external web pages are not allowed. When an address to an external web
page is important, it can be provided (typically in the Reference section) so it can be
copied and pasted into a browser window, but without a hyper link embedded.
IDOC documents and forms associated with an SOP that are in the Reference section,
but are not appendices embedded in the document PDF, should be hyperlinked on a
limited basis. Typically, a hyperlink is used the first time the form or document is
referenced, or when staff are most likely to be referred to the document for use. The
document should also have a hyperlink in the reference section. The decision of internal
hyperlinks location and use reside with the author and/or approval author ity.
10. Definitions
Whenever possible, describe words or terms in the body of the document instead of using a
definition.
Use definitions sparingly and with the following standards:
Do not define a word or term if the meaning is the s ame as or similar to a s tandard
dictionary definition.
Do not define commonly understood words or terms.
Do not define words or terms that are self-explanatory.
Do not define words or terms that are not used in the body of the document.
11. Requesting a Document for Revision or Development
Use the following steps to develop or revise a controlled document:
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Functional Roles
and
Responsibilities
Step Tasks
Approval Authority
or Designee 1
Identify the need to develop or revis e a controlled
document.
Identify an author and when applicable, subject matter
experts (SMEs).
Identify the scope of the revision.
Author 2
Request an editable version of the controlled document
from the policy coordinator.
Policy Coordinator
or Designee 3
Identify the current published version of the requested
document(s) and any revised documents to be
considered.
Review the document formatting.
Update to current format if necessary. (If the author has
the ability and prefers to format the document, the policy
coordinator can skip this requirement.)
Policy Coordinator
or Designee 4
Save the document in the ‘In Progress File’ in the IDOC
document-library computer file.
Create tracking for the document.
Forward the document to the author (Typically, the author
should receive the document within one business day.)
12. Development or Revision Process
The approval authority and author are responsible to determine the process used for
revision based on the complexity of the subject, the scope of the revision, the amount of
time needed, and the availability of resources .
Minor Revisions or Limited Scope
Often a document requires minor revision. For example, one section of the document
needs revised because the procedure or requirement has changed.
The scope of the change is limited; however, the author or policy coordinator can update
formatting, job titles, division titles, and grammar to meet current standards if doing so
does not substantially slow the revision process and doing so does not expand the
scope of the revision. At a minimum, a history revision box must be added to all
revisions.
The approval authority may direct that the update be accomplished without format and
minor editing based on need and resources. In some cases, the policy coordinator may
limit the change to just the needed wording and complete the changes without the
necessity of a division author. If the policy coordinator completes the change, he must
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enable track changes before editing and forward the document to the approval authority
or designee for approval.
When the change is minor, the policy coordinator may publish the document with
approval from the applicable division authority without obtaining DAG review. However, if
the policy coordinator forwards the document to the DAG for review, the DAG should
limit the review to the revised portion of the document. If the DAG determines there are
serious legal concerns beyond the scope of the revision, the DAG must address the
concerns with the approval authority. The approval authority determines whether further
revision is required.
If the DAG provides comments and suggested edits beyond the scope of the revision,
the policy coordinator forwards a copy to the author and files the revised document in
the IDOC Document Library for consideration during the document’s next revision.
Development and Substantial Revision Process
Approval authorities are responsible to make policy decisions or identify individuals to
provide input regarding policy decisions.
The approval authority or designee is responsible to establish the revision or
development process. Typically, the approval authority does the following:
Identify and approve an author to write the document and ensure that the policy
coordinator knows who the author is .
Identify SMEs to provide input and review the document (the author may also be an
SME). Typically, DAG’s are not involved in the development or revision process.
However, the approval authority may also authorize the author to obtain DAG input
during the revision process if necessary. DAG input during the revision or
development process does not negate the need for a DAG review in the final review
and approval process.
The approval authority or designee should vet the document with division managers.
Managers are responsible to have facility SMEs, second-in-command, and other
staff as needed review the document and provide feedback. The approval authority
or designee must review the feedback and make decisions regarding modifications
or additions to the docum ent. Repeat this process as needed until the approval
authority is ready to move forward with publication.
13. Information for Authors
Authors are responsible to write the document clear ly and concisely to the best of their
ability using department writing guidelines. This SOP provides writing aids that authors
should review (sections 7, 8, 9, and 10). Authors are responsible to ensure the document
accurately reflects the policy decisions of division and department leadership and provide s
procedures that assist staff members in the performance of their duties.
Authors determine the best methods for revision, such as using ‘track changes ,’ and for
version control during the revision process.
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Subject Matter Experts
Authors typically use subject matter experts (SMEs) to develop controlled documents.
Standard operating procedures are the most common and com plex IDOC controlled
documents and typically have several SMEs providing input during the process.
SMEs typically provide the most details regarding procedures. SMEs can also provide
input or recommendations regarding policy decisions. If policy decisions are made or
recommended, authors must ensure the approval authority is aware of and approves the
policy decisions .
Document Submission
When the document is finished, the author submits it as an email attachment to the
policy coordinator. If it is a full revision, the document should be a clean document
without track changes . However, track changes and comments can remain if the
purpose is to communicate a need or question to the policy coordinator or DAG during
review.
If the revision is limited in scope, track changes should remain so the DAG can see what
wording was changed (formatting and minor revisions within the document such as
updated division names or titles should not be visible as track changes).
14. Final Review and Publishing Process
The policy coordinator uses the following steps when an author has submitted a document
for publication.
Functional Roles
and
Responsibilities
Step Tasks
Policy
Coordinator or
Designee
1 Save the document in the ‘in progress’ folder in the
document library (ensure it is saved as the correct version).
2
Review document for formatting, grammar, spelling,
version, etc.
Review the document content.
If the document requires editing, turn track changes on,
edit, and return the document to the author for review
(repeat this step as needed).
If the document does not require editing, skip to step 4.
Author 3
Review the edits from the policy coordinator, accept,
modify, or decline the edits.
Review any comments or questions and clarify as needed.
Return to the policy coordinator.
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Functional Roles
and
Responsibilities
Step Tasks
Policy
Coordinator 4
Turn on ‘track changes’.
If the scope of the revision is limited, ensure the sections
revised are highlighted or have the track changes display
the changes.
Forward document via email to the lead DAG and set
deadline for legal review (see deadlines in the subsection
following the process steps).
Lead DAG 5
Review or assign the document to another DAG for review.
Reviewing DAG 6
Review the document focusing on legal issues .
If the revision is limited in scope, the review should focus
on the revisions.
If there are no legal issues , send the document with edits to
grammar, spelling, punctuation back to the policy
coordinator (skip to step 8.)
If a legal issue is present, address the concern with the
applicable approval authority.
Approval
Authority 7
Consider the DAG’s concern and make a decision.
If changes are made, ensure the document is revised.
Forward the document to the policy coordinator.
Policy
Coordinator 8
If the approval authority made or requested any changes
regarding legal concerns, make the changes or ensure the
changes were made (skip to step 10).
If the document contains edits or comments , return it to the
author for review.
If the edits are beyond the scope of the review, the division
may choose to consider those edits during the next
revision. (Save the revised document in the library with the
published version for future consideration.)
If the DAG made no edits or comments, or if the DAG did
not respond within the allotted time, skip to step 10. (If the
DAG did not respond, provide the approval authority with
that information when submitting for approval.)
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Functional Roles
and
Responsibilities
Step Tasks
Author 9
Consider DAG’s edits and discuss with approval authority if
necessary.
Return the final revised document to policy coordinator.
Policy
Coordinator 10
Review the document for formatting, accurate table of
contents, spelling, etc.
Forward document to approval authority for final review and
approval.
Approval
Authority 11
Ensure the correct level of disclosure is indicated.
Approve the document or provide changes needed for
approval (approval can be made via email or so noted on a
hard copy of the document).
15. Review Time Limits
The following time limits are established for review and approval.
Deputy Attorney General
DAGs are given five business days for minor revisions, documents that are brief and/or
simple, and revisions that are limited in scope. DAGs are given 10 working days for full
revisions of documents that are large, complex, and/or warrant close review due to the
nature of the document.
If the DAG office does not complete its review within the allotted time, the policy
coordinator forwards the document to the approval authority noting that the DAG review
had not been received. The review authority determines whether to delay approval until
the DAG review is complete or to approve the document. When the DAG response is
obtained, the policy coordinator forwards it to the approval authority or author for
consideration. The approval authority can make the changes and republish the
document or request that the policy coordinator save the DAG revision for
considerations at the time of the next revision. If the decision is to wait until the next
revision, the policy coordinator saves the revised document in the IDOC Document
Library.
Approval Authorities
Approval authorities are given 10-business days to complete their review and approval.
If the approval authority has not responded within 10-business days, the policy
coordinator contacts the approval authority requesting an update on progress and
continues to contact the approval authority every 10-business days until the document is
approved.
16. Publishing Process
The policy coordinator does the following to publish a document.
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Review the document to ensure the version number is correct, update the table of
contents, review formatting, ensure the correct level of disclosure is marked, and run
spell/grammar check. If any changes to text are made other than spelling
corrections , do so using track changes and return the document to approval authority
or author to review the changes.)
In the IDOC doc management library, move the current versions (Word document
and PDF) from The Library and place them in applicable The Library Archive folder.
Move the new approved version of the document from the In Progress folder to The
Library folder. Create a PDF using the control number with no spaces or periods
such as 1030001003.
Upload the new approved version of the document in PDF format into the web file
management system following eDoc protocols.
Print and compile the DAG’s review, document ow ner approval (typically emails),
and the document.
File the review and approval documentation and the new version of the controlled
document in the permanent hard-copy document file.
Mark the previous version of the document ‘obsolete’.
DEFINITIONS
None
REFERENCES
None
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