• DSHS HIV/STD Program
    Post Office Box 149347, MC 1873
    Austin, TX 78714

    Phone: 737-255-4300

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Policy and Procedure Development and Revision

Procedure Number 396.001
Effective Date  August 20, 1996
Revision Date  January 11, 2011
Subject Matter Expert Special Projects Coordinator
Approval Authority  Branch Manager
Signed by Ann S. Robbins, Ph.D.

1.0 Purpose

To provide guidance on the development and revision of policies and procedures.


2.0 Background

The HIV/STD Prevention and Care Branch, the Epidemiology and Surveillance Branch, and the Health Communications and Community Engagement Group (hereinafter, collectively, the Program) implement a number of different program areas, each with its own set of standards, governing regulations, federal grants, and business practices. The Program also shares many of the same standards, governing regulations and practices across the different areas. As a result, it is important for each area of the Program to document governing principles in policy and procedure, and to revisit these records on a periodic basis to ensure they remain current.


3.0 Definitions

Policy Point Person - Staff person designated to oversee the policy and procedure process and database. See section 6.0 for responsibilities.

Subject Matter Expert - Program staff person or workgroup designated to develop or revise a given policy or procedure content.


4.0 Policy

Any Program staff person, workgroup or group manager may identify the need to develop a new policy or procedure. Each area of the Program is responsible for reviewing policies and procedures affecting their scope of work to ensure they remain updated.


5.0 Procedure

5.1 Creating the Draft

Group area subject matter experts are responsible for all content, which includes writing drafts of new policies and procedures, and for writing draft revisions to existing policies and procedures.

5.2 Internal Review Process

All draft policies and procedures, new and revised, must be submitted for internal review. Internal review begins with other subject matter experts, and may include the group manager or managers and the branch manager. Controversial policies may require review by the Section and Division. The level of internal review is determined by the group manager and/or branch manager. Any revisions arising from the internal review process are the responsibility of the subject matter expert.

Revised or new policies and procedures may require a second internal review process, if after stakeholder input, extensive revisions are necessary.

5.3 Stakeholder Input and Notification for Policies

5.3.1 Key Stakeholder Review

Policies affecting Program contractors or local/regional health departments are recommended be sent to a small group of external stakeholders. This step can support stakeholder buy-in, and provide insight on how a policy might affect and be interpreted outside DSHS and the regions.

5.3.2 Posting for Public Comment

All new or revised policies must be posted for a 30-day public comment period. All public comments received are sent to the policy point person, who forwards to the responsible subject matter expert(s). The responsible subject matter expert(s) may or may not take public comments into consideration in writing or revising a policy. Under certain circumstances, it may be prudent for the subject matter expert(s) to address a public comment directly with the originator. Exceptions to the 30-day Public Comment Period

The public comment period can be shortened to two weeks for policies reviewed and commented on by key stakeholders (see section 5.3.1). Exceptions to posting for Public Comment

Updates to existing policies that do not change the policy itself are not required to be posted for public comment. Example: revisions that update only Branch titles or only renumber a policy.

5.3.3 Stakeholder Input and Notification for Procedures

Procedures directly affecting Program contractors or local/regional health departments are required to follow the process outlined in this section (5.3).

5.4 Notification

Public notification is required for all new and revised policies posted for comment. Public notification is also required for all policies upon adoption, including those described in sections and

5.5 Adoption

Group and/or Branch managers must review final versions of all policies and procedures prior to adoption.


6.0 Responsibilities of the Policy Point Person

The role of the policy point person is to:

  1. Provide technical assistance on policy and procedure development and revision;
  2. Assist with format, numbering and web placement issues;
  3. Maintain the HIV/STD website policy and procedure pages;
  4. Maintain the policy and procedure archive;
  5. Assist in posting policies and procedures for public comment;
  6. Acknowledge receipt of public comments directly with the originator;
  7. Initiate public notification when a draft policy is posted;
  8. Act as main point of contact for all public comment for policies and procedures posted for input; and
  9. Initiate public notification when a policy is adopted.


7.0 Revision History

Date Action Section
10/8/2014 Converted format (Word to HTML) -
1/11/2011 Extensive revision. Considered new procedure. All
5/4/2006 Four policy writing procedures combined. All



Last updated May 24, 2021