Florida GulfCoast University 2024 Compliance and Ethics Program Plan  A. INTRODUCTION  1. This document serves as a blueprint of an effective compliance and ethics program plan as contained in the Federal Sentencing Guidelines Manual (Chapter 81 Part B, Section 2.1(b)) and the Board of Governors (BOG) Regulation 4.003, State University System 2. Ina accordance with the Manual and the BOG Regulation, FGCU's Compliance and Ethics Program Plan (hereinafter referred to as Compliance Plan) outlines the seven elements of an effective compliance and ethics program. The Compliance Plan demonstrates due diligence inj preventing and detecting criminal conduct, unethical behavior, and noncompliance with rules; and promoting an organizational culture that encourages ethical conduct and a commitment to compliance. Specifically, the Compliance Plan: a. Implements written standards in the form ofa Code of Conduct toj promote responsibility and accountability for ethical conduct, as well as the University's commitment to compliance with applicable laws, regulations, rules, policies, and b. Establishes an administrative governance framework, including the designation ofa Chief Compliance Officer, for conducting an effective and diligent compliance Outlines a commitment to educate University personnel regarding compliance d. Develops effective lines of communication to encourage reporting allegations of wrongdoing without fear of retaliation and to receive and respond to deficiencies and Implements monitoring and auditing functions to measure the effectiveness oft the C Outlines performance incentives and disciplinary measures to promote and enforce - Outlines a process to timely review credible allegations of wrongdoing, take corrective actions, and implement appropriate and effective internal controls to  Compliance and Ethics Programs.  procedures.  program.  requirements and ethics initiatives.  breaches in an efficient and timely manner. University's compliance initiatives. the compliance and ethics program.  prevent further similar misconduct from occurring.  Florida Gulf Coast University 2024 Compliance and Ethics Program Plan  Page 1 of1l    B. THE SEVEN ELEMENTS 1. Code ofConduct  a. The University's Code of Conduct promotes ethical principles derived from federal and state laws and regulations, University regulations and policies, contract and grant requirements, and generally accepted principles of ethical conduct. The Code applies tot the President, Cabinet, and University faculty and staff; and volunteers, contractors, vendors, and other representatives providing services to or acting on behalf oft the University. Deans are responsible for ensuring that faculty under their supervision abide by the Code; managers ofUniversity administrative functions are responsible for assuring that staff and other representatives under their supervision abide by the Code. The Chief Compliance Officer is responsible for promoting, b. The Code of Conduct supplements the University'sr regulations and policies, and, in particular, complements the University's Regulation on Ethics as well as the FGCU Board ofTrustees Ethics Policy, both ofwhich reaffirm the University's commitment to comply with the Code of Ethics for Public Officers and Employees codified at Title - Ac copy ofthe Code of Conduct is provided as an attachment to the Compliance Plan.  monitoring, and enforcing the Code.  X, Chapter 112, Part Ill oft the Florida Statutes.  2. Compliance Program Governance  FGCU displays an appropriate governance structure by ensuring that the FGCU Board of Trustees, through its Audit and Compliance Committee, is knowledgeable about the content and operation of the compliance and ethics program and exercises reasonable oversight over its implementation and effectiveness. A Chief Compliance Officeri is assigned responsibility for the day-to-day operations of the program and is afforded direct access to the Chair oft the FGCU Board of Trustees and the Chair of the Audit and Compliance Committee oft the FGCU Board ofTrustees, as well as to the President and Cabinet, University employees with compliance responsibilities, and University a. Audit and Compliance Committee oft the FGCU Board ofTrustees  employees responsible fori investigations as follows:  The Audit and Compliance Committee oft the FGCU Board ofTrustees is responsible for overseeing the compliance and ethics program and approving of the roles and responsibilities of the Chiefc Compliance Officer. As required by BOG Regulation 4.002(2), the Charter for the Audit and Compliance Committee ofthe FGCU Board ofTrustees describes the Committee's governance oversight for FGCU's compliance  and ethics program.  Florida Gulf Coast University 2024 Compliance and Ethics Program Plan  Page 20 of11    b. President ofl FGCU  In collaboration with the Chair oft the. Audit and Compliance Committee oft the FGCU Board ofTrustees, the President designates a senior-level administrator as the Chief Compliance Officer and ensures that the individual selected for the position maintains his/heri independence and has adequate resources and authority to perform the  responsibilities of the position. C Chief Compliance Officer  The ChiefCompliance Officer is responsible for the day-to-day operations oft the compliance and ethics program. To ensure the impartial and unbiased judgment essential to the proper conduct oft the compliance and ethics function, the Chief Compliance Officer is organizationally independent oft the employees and managers who seek the advice and assistance of the Office. The ChiefCompliance Officer reports functionally to the Chair of the Audit and Compliance Committee of the FGCU Board ofTrustees and administratively to the President; and is afforded unrestricted access to University information, documents, records, and personnel necessary to carry out the duties and responsibilities oft the Office. The Charter for the Compliance Office outlines the purpose, authority, mission, scope of work, and  responsibilities ofthe Office. d. Vice Presidents (Cabinet)  The President's Cabinet, comprised ofthe University's Vice Presidents, is responsible for advising and supporting the ChiefCompliance Officer in the implementation and oversight of the compliance and ethics program. The Vice Presidents set an "appropriate tone at the top" by fostering a culture of ethical conduct and performing their duties in compliance with all applicable laws, regulations, rules, policies, and procedures. In addition, the Vice Presidents ensure that compliance programs under their responsibility have adequate resources to effectively conduct operations.  Compliance Liaisons  1) The Compliance Liaisons are University employees designated with carrying out compliance-related responsibilities for a specific program or function within the  University, including, but not limited to the following:  Topic  University Unit  Academic Integrity Americans with Disability Act (ADA) Athletics and NCAA Rules Biohazardous Waste, Biosafety, and Bloodborne Pathogens Clery Act  Dean of Students Adaptive Services Athletic Compliance Environmental Health and Safety University Police Department  Florida Gulf Coast University 2024 Compliance and Ethics Program Plan  Page 3 of11    Compliance with Regulations and Policies General Counsel or Institutional Equity  and Compliance Institutional Equity and Compliance/Title IX General Counsel Environmental Health and Safety Counseling and Wellness Services University Advancement Environmental Health and Safety Research and Sponsored Programs Financial Aid and Scholarships Institutional Equity and Compliance/Title IX Internal Audit Institutional Equity and Compliance/Title IX Human Resources Business and Technology Services Research and Sponsored Programs Research and Sponsored Programs Environmental Health and Safety Research and Sponsored Programs Research and Sponsored Programs Institutional Equity and Compliance/Title IX Procurement Records Management Research and Sponsored Programs Controller Internal Audit  Conflicts of Interest Contracts Controlled Substances Counseling and Wellness Donations/Endowment Environmental Protections Export Controls (FERPA) Financial Aid Financial Disclosure Fraud, Waste, and Abuse Harassment, Intimidation, Retaliation, Discrimination Hiring Background Checks Information Security Institutional Animal Care and Use Committee Institutional Review Board Insurance (Risk Management) Intellectual Property Misconduct in Research Outside Activities Procurement Records Management Sponsored Programs Taxation Whistleblower Protection  Family Educational Rights and Privacy Act  Registrar  2) The Compliance Liaisons provide the ChiefCompliance Officer with immediate notification of suspected or detected non-compliant behavior, unethical behavior, or criminal conduct; and on an annual basis, a summary of compliance initiatives. In addition, University personnel with compliance responsibilities meet ona quarterly basis to discuss program activities and new and supplemental changes to laws, regulations, rules, policies, and procedures in order to stay abreast of best practices in the compliance sector. The ChiefCompliance Officer chairs these  meetings.  Florida GulfCoast University 2024 Compliance and Ethics Program Plan  Page 40 of11    3. Education/Training  The ChiefCompliance Officer provides ethics training on a biennial basis to members of the FGCU Board ofTrustees. Ethics training is provided annually to the President, Cabinet, faculty, and staff regarding the responsibility and accountability for ethical conduct and compliance with applicable federal and state laws and regulations as well as University policies and regulations. New employees also receive an initial ethics overview via New Employee Orientation and New Employee Training to introduce FGCU's compliance and ethics program, including the Hotline, Code of Ethics contained in Florida Statutes, the University's Code of Conduct, and other relevant regulations and policies. They are also required to review and acknowledge receipt of the University's  Code of Conduct within the first 60 days of employment.  4. Communication  FGCU displays a proactive commitment to compliance by encouraging open communication of compliance and ethics issues, and the reporting of good-faith concerns  ofalleged wrongdoing, without fear of retaliation. a. Communication to Employees  The ChiefCompliance Officer disseminates information about FGCU's compliance and ethics program and FGCU's Hotline. Compliance Liaisons disseminate information about new legislation and updates to current legislation affecting the programs for which they are responsible. Below are some examples of how 1) Correspondence from Compliance Liaisons concerning new or amended legislation regarding NCAA compliance, Clery Act, Title IX, compensation and benefits, sponsored programs, financial aid, whistleblowing, or environmental  communication occurs:  health and safety.  2) Posters and emails promoting the FGCU Hotline.  3) Training initiatives sponsored by the Office ofInstitutional Equity and Compliance; or Office ofl Environmental, Health and Safety.  b. Communication from Employees  FGCU promotes collaboration by encouraging faculty and staff to bring forward questions or seek clarification on any federal or state law or regulation or FGCU policy or regulation before taking action on a University matter. Employees can ask their supervisor or manager, Vice President and General Counsel, or the Chief  Compliance Officer for advice and assistance.  Florida Gulf Coast University 2024 Compliance and Ethics Program Plan  Page 5 of11    C. Communication to President and FGCU Board of Trustees  The Chief Compliance Officer meets regularly and in no event less than four times a year either inj person or telephonically with the Chair ofthe Audit and Compliance Committee to review all compliance and ethics-related matters of importance and all credible evidence of alleged misconduct, including criminal misconduct. Other senior members of the administration including the President are welcome to attend any such session. The Chief Compliance Officer shall also promptly inform the Chair ofthe Audit and Compliance Committee of any serious matters under the purview oft the Compliance Office arising between meetings. 2) The Chief Compliance Officer provides the FGCU Board ofTrustees with an annual report on the effectiveness of the compliance and ethics program. Upon approval, a copy ofthe annual report is provided to the Board ofGovernors. 3) The Chief Compliance Officer meets with the President on a weekly basis and  Cabinet on an as-needed basis.  d. How to Report Concerns  1) FGCU's Hotline is an anonymous reporting system that facilitates reporting of alleged illegal, unethical, ori improper conduct when the normal channels of communication have proven ineffective or are impractical under the circumstances. The Hotline is available to employees and students, as well as contractors, vendors, and members oft the southwest Florida community. Ifan individual is unsure ofhow to bring forward a concern, they can always contact FGCU's Chief Compliance Officer for assistance, but ifa an individual is uncomfortable reporting through normal channels of communication, or wishes to raise an issue anonymously, they should access the Hotline. 2) The Hotline is available 24 hours a day, 365 days a year, and is run by an independent, third-party provider. The Hotline provides a toll-free telephone  number as well as web-based reporting. 3) An individual can contact the Hotline by: a) Calling the Hotline at (844)989-2950; or  b) Completing an on-line form at the following link: wwfgeuctlhspintcom. 4) Hotline concerns remain confidential to the extent permitted by law and are only shared with certain University stakeholders and external entities on a need-to- know basis. The Hotline has no caller identification and does not track IP addresses. FGCU prohibits retaliation, and will take no adverse action, against an individual who uses the Hotline in good faith to report allegations of wrongdoing.  Florida Gulf Coast University 2024 Compliance and Ethics Program Plan  Page 60 of11    5) In addition to the Hotline, employees can bring good-faith concerns to: a) The ChiefCompliance Officer for violations of University policies or b) The Office of Institutional Equity and Compliance, for harassment, discrimination, retaliation, and sexual misconduct allegations; c) University Ombuds for informal, impartial, and non-adversarial alternatives  regulations;  concerning conflict management; d) Their supervisor or manager;  e) Assistant Athletic Director for Compliance forl NCAA compliance concerns; Associate Vice President for Research and Sponsored Programs for research g) Dean of Students, Care, and Conduct for student Code of Conduct and h) Director ofInternal Audit for fraud, waste, and financial mismanagement Director ofl Environmental Health and Safety for environmental health and  misconduct concerns; academic integrity concerns; allegations; or safety concerns.  5. MonitoringAuditing  FGCUi implements a self-assessment program to monitor and evaluate compliance functions throughout the University. Through its Compliance Liaisons and Director of Internal Audit, FGCU conducts ongoing efforts to assess, evaluate, monitor, and audit compliance with regulatory requirements and University regulations and policies.  a. - Compliance Liaisons  Compliance Liaisons conduct periodic risk assessments to evaluate and prioritize compliance related risks. This assessment entails evaluating factors such as audit results, recent litigation and settlements, compliance concerns, University best business practices, and the existence and sufficiency ofr regulations and policies covering an area. Based on the risk assessments, Compliance Liaisons monitor high- risk areas under their responsibility. The Chief Compliance Officer assists Compliance Liaisons with the implementation of proper and effective internal controls to reduce the risk ofnoncompliance and refers high risk areas to Internal Audit for consideration of inclusion in the. Annual Audit Plan.  Florida Gulf Coast University 2024 Compliance and Ethics Program Plan  Page 7of11    b. - Director of Internal Audit  The Director ofl Internal Audit oversees the performance of value-added, risk- based audits, designed to independently review, test, and evaluate financial, electronic, and operational controls throughout the University in order to examine and assess:  1) Business risks facing University leadership; 2) Safeguarding and use ofUniversity assets;  3) Accuracy, reliability, and integrity ofUniversity records and reports; 4) Suspected fraud, waste, and financial mismanagement; and  5) Adequacy ofi internal controls. C Chief Compliance Officer  The Chief Compliance Officer assesses whether the compliance and ethics program maintains organizational independence, has appropriate access to University records and personnel, disseminates standards and other communication, conducts training, responds appropriately to detected offenses, and implements effective corrective action plans to preclude future similar offenses from occurring.  d. Background Checks  FGCU uses reasonable efforts not to include within the University and its affiliated organizations individuals who have engaged in unethical conduct or inappropriate behavior. FGCU'sproceurement function reviews state and federal lists of debarred contractors and vendors to prevent them from conducting work or providing services tothe University. FGCU's police department conducts background checks on  prospective employees. 6. Incentives and Discipline  a. FGCU demonstrates a commitment to compliance by reviewing University policies and regulations as well as the University's Code of Conduct in New Employee Orientation. In addition, the University incentivizes supervisors who encourage employees to take ethics training and speak openly about concerns in the workplace; and supports employees who act with integrity and make sound decisions in the best b. FGCU promotes a speak-up culture by encouraging its employees to use the University's reporting systems to bring forward good-faith concerns ofwrongdoing. FGCU takes appropriate disciplinary action based on progressive and cumulative  interest of the University.  Florida GulfCoast University 2024 Compliance and) Ethics Program Plan  Page 8of11    discipline as outlined in the University Regulation on Disciplinary Actions, against members ofi its workforce who violate the University's Code ofc Conduct or Regulation on Ethics and who fail to correct their behavior. d. Ina addition, managers and supervisors can be disciplined for failing to adequately instruct subordinate employees or failing to detect non-compliance with applicable policies and legal requirements, where reasonable diligence on the part ofthe manager or supervisor would have led to the discovery of problems or violations and given the University the opportunity to timely correct the issue(s). Disciplinary action may include oral or written reprimand, suspension, or separation from employment. Violations may also result ini notification to law enforcement officials, BOG Inspector General, regulatory bodies, and accrediting and licensing  organizations, as appropriate. 7. Responding to Detected Offenses  a. The ChiefCompliance Officer serves as the administrator for all allegations of potential wrongdoing reported through the University's Hotline. In collaboration with Compliance Liaisons, the Chief Compliance Officer determines the appropriate resources required to conduct an investigation commensurate with the gravity of the allegation and refers certain matters to an appropriate investigatory body for review and disposition. The Director of Internal Audit is responsible for conducting reviews pertaining to credible allegations of fraud, waste, and financial mismanagement, and the Office of Institutional Equity and Compliance is responsible for conducting reviews pertaining to harassment, retaliation, and discrimination concerns.  b. Investigation records will contain:  1) Documentation of the alleged violation;  2) Documentation of referral to an internal or external investigatory body;  3) Description of the investigative process; 4) Interview notes and copies of key documents;  5) A log of witnesses interviewed and documents reviewed; and  6) Results of the investigation.  Ifthei investigation indicates that a violation has occurred, FGCU will take  appropriate corrective action, as necessary, including: 1) Prompt restitution ofany overpayments;  Florida GulfCoast University 2024 Compliance and Ethics Program Plan  Page 9of11    2) Notification to a grantor agency;  3) Review of FGCU regulations and policies to determine ifclarification is needed;  4) System modifications; 5) Staff training;  6) Notification to BOG Inspector General; and 7) Disciplinary action ofinvolved employees.  Florida Gulf Coast University 2024 Compliance and Ethics Program Plan  Page 10of11    Prepared by:  91/24 Date  Officer  yhala N  Revicwed by:  oligl2024 Date  President  Aaw5 Aysegul Timur,  Aoy - Josepl G. Fogg, III, Approved by:  glbe Date  Coimpliance Committee  acis  I -  gfofy Daté  Michael Wynn, Chair, Board ofT Trustees  Florida Gulf Coast University 2024 Compliance and Ethics Program Plan  Page llof1l