Policy Approval Template

Policy Name: Insert name here.

Policy Number: Insert number here.
Approval Date: Insert date here.
Originating Committee: Insert name here.
Entity Responsible for Implementation and Monitoring: Insert name here.
Review/Revision Schedule: Insert date here.
LCME Required Policy: Yes/No
LCME Element(s) Number and Description: Insert number and description here.
Review/Revision Date(s): Insert date shere.
Policy is Applicable To: Insert name here.
Purpose of Policy: Insert purpose here.

Approved By and Date:

Insert Name and Date here.
Insert Name and Date here.

Review/Revision Completed By and Date:

Insert Name and Date here.
Insert Name and Date here.

Notified Groups, Date(s), and Method of Communication:

Insert Name, Date, and Method of Communication here.
Insert Name, Date, and Method of Communication here.

Related Policies:

Insert Policy here.
Insert Policy here.