Internal Policies and Guidelines

in the Department of Psychiatry and Behavioral Sciences

This page summarizes important internal policies around a range of important matters that affect day-to-day practice and longer-term planning.   

View past editions of our Policy Update newsletter:  February 2019

Electronic Equipment Purchases

The School of Medicine requires that all newly purchased computers, tablets, and mobile devices must be encrypted prior to being put into operation.

Due to mandate above, computer and software purchases using any University Funds (grants/etc) in the Department must be procured centrally and requires IT approval. This is essential to ensure the department is in compliance with the rest of the School.

All desktop and laptop computer purchases (including software, accessories, data storage units, and other components) must be made through SOM IRT. 

For more information, please visit the SOM's recommendations and procedures for computer purchasing page.

1. Purpose

The purpose of this guidance is to outline the roles, responsibilities and procedures for the electronic equipment purchases to ensure all purchases meet Stanford’s financial and network security compliance.

2. Scope

This guidance is applicable to all electronic equipment (with > 16G memory capacity) purchases using Stanford funds for Stanford business.

3. Key Terms

  • User and/or Originator: Individual who requests and/or initiates the purchase.
  • SoM IRT: Information Resource Technology team from School of Medicine.
  • Approver: Finance Manager or her/his designee who has authority over the PTA.
  • Business Purpose: Summary of justifications (Who, What, When, Where, Why) for the purchase.

4. Roles and Responsibilities

  • A. User and/or Originator: Complete a SoM IRT Help Ticket via IRT will forward the shopping cart to Originator via iProcurement SmartMart Portal.

    Originator will complete and submit shopping cart to finance manager for final approval.  When submitting a SoM IRT ticket, Originator will provide the following information:
    • Make/model and business purpose statement for the purchase.
    • PTA information.
    • Finance Manager’s information.
  • When Shopping Cart is received from SoM IRT, Originator will complete the following information:
    • Add IRT RITM# to Description section.
    • Update address field.
    • Verify PTA and Expenditure Type information.
    • Submit to Finance Manager for approval.

B. SoM IRT: Review and verify specifications of electronic equipment to ensure the purchase meets Stanford Network Security. Create a shopping cart in iProcurement portal and forward it to Originator.

C. Financial Approver: Review and verify business purpose, PTA, expenditure type and approve requisition per protocol.

5. Additional Remarks

Once the requisition is approved, Purchase Order (PO) will be generated and emailed to vendor directly. Originator will receive email notification on shipping and delivery information. Equipment will be shipped directly to SoM IRT Procurement Team. Once the equipment is verified to meet Stanford Network Security policy, SoM IRT will schedule a time of delivery to User and/or Originator.

PCard should not be used as the primary source to purchase electronic equipment. Exception can be made for IRT approved equipment that is not available in Stanford iProcurement Portal. Waiver needs to be submitted to SoM IRT for research equipment that does not meet Stanford Network Security Policy.

Research-based EPIC access policy & procedures

version August 2017

Access to Stanford Healthcare (SHC) electronic health records is an area that is tightly controlled by law for patient privacy and protection. Medical records are covered by HIPAA and require that procedures protecting patient privacy are followed. Please note that there are many policies and procedures around Epic health records that are documented by SHC and the School of Medicine (SoM).  They are not included here as they have their own living spaces on a range of websites. For example, see Stanford University HIPAA Privacy Policy H-13 Minimum Necessary Use and Disclosure of, and Requests for, Protected Health Information and Stanford University HIPAA Policy H-14 Research and Patient Privacy at  

Unauthorized access to health records is a terminable offense and granting access to research staff should not be taken lightly. The following process is for access to Epic for research-related activities. Any data to be retrieved by research staff must be done with (a) review and approval by the IRB prior to a request for Epic access and (b) view-only access.

Research-based EPIC access procedures

Epic access for LPCH and SHC are handled by two different avenues.


Information on LPCH Epic access requests can be located here:

This is the SOM approved route for requesting research staff LPCH Epic access.


Access to SHC Epic is a two part process of (A) gaining access to Epic and then (B) getting the correct training in order to have a complete coordinator view.

A) Gaining Access to EPIC

Requests should be routed to Aimee-Noelle Swanson and include the following information for the grantee:

  1. Legal First Name:
  2. Legal Last Name:
  3. University e-mail address:
  4. Title:
  5. Stanford University Employee ID # (on badge)
  6. Level of access: READ ONLY [this is the only option]
  7. Supervisor’s name:
  8. Supervisor’s e-mail address:
  9. IRB protocol(s) person is working on:
  10. Is it included in your IRB application(s) that you will be accessing SHC records?
  11. Please confirm that you will not be using any patient appointment information for recruitment – unless approved by the IRB.
  12. Does this person already have an SID (issued by SHC for Epic access)?
    1. The answer is typically ‘No.’
    2. We include the request for an SID with the request for view only access.

Additionally, please have the supervisor (faculty PI) complete the SOM E&HS Qualtrics survey which is required for the Healthstream training:

B) Required Training

Once the grantee receives the SID (5-7 days after initial request), email Epic Education the following information in order to set up your Healthstream account and assign the appropriate SHC Epic training –

    Department: Psychiatry & Behavioral Sciences
    Job Position / Role:
    Stanford University Employee ID #: (on your badge)
    SID: (7 digit number with an S prefix. Ex: S0123456)
    And, tell them that your supervisor has already completed the E&HS survey (if they indeed have)

Once they have this information, you’ll be assigned a Healthstream account number and signed up for two courses:

(a)   Required ‘view-only’ SHC Epic course in Healthstream: SHC Epic 867 Read Only Ambulatory and Inpatient
Your Epic account will be activated with view only access 24 hours after you complete the course.

(!) In order to have your view-only Epic access upgraded to Clinical Research Coordinator access, you must attend the Epic Research Coordinators instructor-led class described below.

(b) SHC Epic 144 Research Coordinators (4 hours)
Epic navigation, order transcription, CRM use, Charting tools and Telephone encounters for School of Medicine Research Coordinators and Clinical Trial Coordinators.

  • Epic workspace/toolbar overview and customization
  • Schedule and schedule reports
  • Chart Review and Chart Search
  • SmartTools (Smartphrases)
  • Orders
  • CRMs
  • Telephone Encounters
  • Epic Help Resources

Research Cost Policy Guidelines

The University and the School of Medicine have adopted practices that affect Fellow, Postdoctoral, and Graduate Student research funding, as many of you are aware.   These practices create greater resource challenges on faculty throughout the institution.  We are writing to signal our understanding of the stresses associated with these challenges and to make clear how the Department is handling these practices.

The first major issue relates to the infrastructure charge associated with non-NIH funding sources for research and other projects.  The Stanford University policy is that sponsored projects that do not cover indirect costs (also known as F&A or overhead) are subject to an 8% infrastructure charge (ISC).  As a consequence, when applying for a sponsored research project that covers 0% F&A and/or explicitly states that it does not cover indirect costs, the faculty mentor will be asked for an alternate unrestricted PTA to cover this charge.  It is essential to plan ahead – the Department at this time is not able to pick up these charges, especially across multiple research groups and many dozens of potential PIs in the Department.  For this reason, we ask that you please be sure to look carefully at the terms and conditions of grants prior to submitting an application. If a funding opportunity does not cover 100% of salary, benefits, and indirect costs, the faculty mentor must draw on his/her own resources to cover this difference.  Also note that gift funds cannot be used to cover the 8% ISC charge.  Please refer to the following documents for more information:

Stanford University Administrative Guide: Infrastructure Charges

Stanford University Office of Sponsored Research: Infrastructure

A second issue pertains to health insurance for postdocs.   All postdocs at Stanford are required to have medical insurance coverage.  For clear reasons, we as a Department support this policy.  Postdoc benefits are funded either by the application of an approved fringe benefit rate to the salaries of qualifying (50% salary or more) postdocs, by fellowship awards, or (in the absence of one of these two sources) by the scholar's faculty mentor. While many postdoc funding opportunities provide coverage for health insurance, the amount may not be sufficient for coverage of all aspects of medical insurance. For example, enough resources may be provided by a fellowship to cover health insurance for the individual, but not the entire family.  These costs are borne by the faculty mentor and represent a significant financial challenge, particularly in larger laboratories.  Please review the terms and conditions of funding opportunities prior to submitting an application as these costs are the responsibility of the faculty mentor.

A similar issue relates to the minimum salary for postdocs at Stanford.  Stanford University has its own minimum salary scale based on years and months of experience for postdocs.  These salary levels differ from NIH salary rates or salary coverage on fellowships. To give one example, a postdoc coming in on a T32 fellowship with 1 year and 1 month experience may be eligible for $50,376 as salary derived from NIH funding; however, the Stanford minimum salary for a post-doc with this level of experience is $60,000.  The Stanford rate takes precedence and the faculty mentor then is required to provide support to bring the postdoc up to the minimum.  Again, it is correct that we compensate our early career colleagues in a fair and equitable manner, but the lack of alignment with federal compensation parameters represents a significant challenge in our research-committed environment.

Please refer to the following document for more information:

Stanford Office of Postdoctoral Affairs: Funding Guidelines

An additional cost that is the responsibility of the faculty mentor are occupational health surveillance costs.  Medical surveillance is the process of evaluating the health of employees, as it relates to potential exposure to hazardous agents. Environmental Health & Safety (EH&S) determines which job classifications require surveillance. Inclusion in the medical surveillance program is based on industrial hygiene and safety surveys, in which exposures to various stressors were evaluated.  For research staff who may have direct patient/human subject care or work in patient care areas,  the Department will cover the following required health surveillance costs for regular benefits employees (RBE) only (that is, not contingent staff): Health/Medical Hx Questionnaire review, TB questionnaire review, TB skin test (PPD).  All other health surveillance costs or costs for contingent employees are the responsibility of the faculty mentor and/or the employees’ own health insurance.  

Finally, any work proposed by a trainee or postdoc must fit into the existing space allocation of the faculty mentor.  Given our finite space allocation, it is not possible to provide space to all of the worthy trainee projects.  We ask that you consider your space allocation and the feasibility of a new project in that allocation before moving forward with a new program consideration.

These institutional practices are important to understand and manage.  We in the Department are prepared to assist you with information-gathering and to work with you in planning for your groups.

SUNet and Email Sponsorship Policy

version February 1, 2018

SUNet IDs allow individuals access to Stanford-based systems and names the individual as a member of the Stanford community.

Anyone who is not University Eligible, but requires a SUNet ID, is sponsored by a department at Stanford. You may be sponsored for a BASE (SUNet ID, VPN access, etc; free) or a FULL (email, web service, etc; monthly fee) package. Sponsored accounts are valid for fixed periods of time and may have restrictions that University Eligible SUNet IDs do not.

  • Department approval must be obtained for base sponsorship for contingent employees, non-Stanford students, and members of the Affiliated & Adjunct Clinical Faculty, Affiliated & Adjunct Instructors/Professors, & Visiting Faculty/Scholars (please see below for further information).
  • These requests will be approved on a case-by-case basis.

Being assigned a SUNet ID means that the individual agrees to Stanford’s Computer and Network Usage Policy (, in addition to Stanford’s Information Security Policies (, Privacy and Security of Health Information (HIPAA) (; see also, and Privacy and Access to Electronic Information (  

SUNet IDs present significant challenges in our environment as they also can allow access to PHI or other data protected by HIPAA. As a community, we take the protection of confidential and sensitive health information seriously and want to be good citizens in our efforts to safeguard the trust that both research subjects and patients have placed in us. In particular, the use of a Stanford-based email account must be tempered with strict consideration of our institutional policies and requirements for protection of personal health information.

Requests for BASE SUNet IDs for research staff (or for research-based purposes) are routed to Aimee-Noelle Swanson, Director of Research, Integrity, and Strategy. You will be asked for the reason that a SUNet ID is needed and the eProtocol number for the study that the staff member is working on.  Any research staff having contact with human subjects, PHI, or sensitive data should be listed on an active IRB protocol.  

Requests for a FULL account will require a PTA where the full account can be charged, in addition to a strong justification for the need of a Stanford email account. These requests will be routed to Aimee and Heather Kenna, Director of Faculty Affairs and Strategic Planning. Persons with Stanford email addresses are expected to comply with all University and School of Medicine policies with regard to privacy, confidentiality, usage, etc. (see; Note that full accounts for employees generally are not an allowable charge on NIH or Federal funds.  We will work hard to turn these requests around quickly and with little complication.

As Sponsorship is a separate system from employment, it is the responsibility of the person requesting the SUNet ID to notify Heather or Aimee if the SUNet ID needs to be terminated.  This does not happen automatically at the end of employment

Also, as a gentle reminder, all email relating to University business is the property of Stanford University. This includes email stored on personally owned computers, mobile devices (laptop computers and smart phones).

Reimbursement of Board Certification, Licensing and DEA Fees, and Required Maintenance of Board Certification

Effective September 1, 2017

The Department will typically reimburse eligible full-time (1.0FTE) faculty for their out-of-pocket expenses related to California clinical licensure (i.e., medical or psychology). Eligible physician faculty may also be reimbursed for their out-of-pocket fees related to DEA registration and board certification (including both general boards and subspecialty boards), if required for their job.

The Department will also typically reimburse eligible full-time (1.0 FTE) members of our faculty for out-of-pocket application and examination fees related to successful board certification and re-certification.  This includes fees for general board certification, as well as subspecialty board certification.  Please note that the Department cannot cover preparation materials or courses or travel or late fees associated with board examinations or board preparation courses.

To be eligible for reimbursement for California licensure, California DEA fees, or board certification fees, a few conditions must be met. The faculty member must have a full-time (1.0 FTE) appointment and be based at Stanford. The licensure or DEA cost must be an actual "out of pocket" expense, i.e., not be paid by another organization. If the faculty member has at least 0.1 FTE clinical effort, fees can be charged to the appropriate division clinical account ("PTA").

Faculty who are employed less than full-time may request an exception for reimbursement if they are employed at least 50% time or greater. Such requests should be submitted to the DFA, Indy Singh. For an exception to be considered, the faculty member must be in good professional standing and have no clinical activity outside of his/her Stanford faculty role.

Strengthening our Department's capacity to provide subspecialty care is important to fulfilling our academic mission and serving our community.  Our leadership team strongly encourages all faculty who are eligible to pursue subspecialty board certification.   Please speak with your Division or Section Chief about pursuing additional subspecialty board certification, if you are interested.

We would also like to take a moment to remind everyone that maintaining general board certification/licensure is a fundamental expectation for members of our faculty.  Maintenance of certification and of up-to-date state licensure are required by the School of Medicine and our affiliated hospitals for all faculty members with clinical duties.  We sincerely appreciate your attention to these responsibilities.  

We hope that this expanded reimbursement approach will lessen the burden of professional expenses for our faculty.  Katherine Wong is the department contact for all license and board maintenance-related reimbursements.

Process for Prospective Departmental Review of Industry-Sponsored Clinical Trial Proposals

April 2017

Industry-sponsored clinical trials provide access to new, novel medications and devices and allow faculty to be part of cutting-edge research.  Faculty are encouraged to pursue all research proposals that are aligned with their intellectual interests, including industry-sponsored trials.

However, these trials can involve substantial challenges both to the Investigator and the Department. For example, lower than budgeted enrollment and unreimbursed expenses are frequently encountered. 

In order to keep information between faculty and the Department Administration open and clear so that all parties are aware of future effort, time commitments and financial obligations, the Department policy since September 2013 has been that industry-sponsored clinical trial contracts and budgets will require a prospective departmental review by the Chair or the Chair's designee.

With the understanding that there are already existing concerns regarding the amount of time it takes to gain clinical trial approval from the School of Medicine, the department commits to completing our prospective review in 5 business days once we have all of the information required for review.


  1. The Clinical Trials-Research Management Group (CT-RMG) will notify the Department when they are presented with an industry-sponsored clinical trial by Department faculty;
  2. CT-RMG will send the Director of Research Development, Integrity, and Strategy (Aimee-Noelle Swanson) the proposed scope of work and budget for review;
  3. Department will review the proposal in 5 business days or less;

Department will e-mail PI and CT-RMG to move forward with the proposal and to prepare for implementation.
Please also note, if the trial is required to be listed on, it is essential that the record be updated in compliance with FDA guidelines.  Failure to do so will prevent future proposed trials from commencing without earlier records being updated.

Information on Email and Text Messaging with Protected Health Information (PHI)

January 2017


When sending PHI via e-mail, the e-mail must be sent securely.  This is done by placing ‘Secure:’ in the subject line of the email.  See

Emails containing PHI should only be sent from a or or e-mail account.  School of Medicine (SoM) faculty, staff, and students and Hospital employees (Stanford Health Care/Stanford Children’s Health) should not use their personal e-mail accounts to communicate with patients or research participants.  Also, there are specific rules surrounding e-mailing research participants. How to register for Secure Email:


SoM and Hospital employees are not allowed to send PHI via text messages (regardless if the device is owned by Stanford).  The Hospitals have the policy regarding text messages and the University reiterates the rule in HIPAA training.  For both the University and Hospitals, text messaging in not an approved method to send or receive High Risk Data (PHI).  See

Guidance and Links for Use of Stanford Logo/Name, Review and Approval of Press Releases, and Engagement with Media

December 2017

The SOM Office of Communication & Public Affairs needs to review and approve any press release that involves Stanford SOM.  External announcements must also receive approval for any use of the Stanford name, logo, and marks.  Of note, there is typically no use of the term “partnership” per University policy in these statements.  The Office of Communications and Public Affairs will work with you on sorting out the language.

For more information on SOM Logo and Name usage, please visit:, for University, please visit: and

For tips from the University Communications Office on working with the media, please visit: