Documents Submitted for Commission Review

Institutions accredited by The Commission are requested to submit various documents for review by an evaluation committee or The Commission Board of Trustees. Those documents include:

Compliance Certification Focused Report Quality Enhancement Plan Documentation for an Interim Off-Campus Instructional Sites Committee Review Documentation for a Substantive Change Committee Review Fifth-Year Interim Report Institutional Special Report Substantive Change Submissions Response Report to the Visiting Committee Referral Report Follow-Up Report Monitoring Report

When submitting a document, an institution should follow the directions below, keeping in mind that the document will be reviewed by a number of readers, most of whom will be unfamiliar with the institution. The institution must also comply with the appropriate deadline for submitting the document. These deadlines may be found either published on The Commission website, in formal correspondence from The Commission staff, or via The Commission Institutional Portal. Documentation for review by an Accreditation Committee, an On-Site Reaffirmation Committee, an Interim Off-Campus Instructional Sites Committee, or a Substantive Change Committee authorized to visit the institution is due to the members of the Committee and to The Commission staff six weeks before the start of the visit. All documents, including both narratives and supporting evidence demonstrating compliance with the Principles of Accreditation, must be in English. Audits must be presented in U.S. dollars and all notes in the audits must be in English.

Member institutions are expected to submit all documents by the appropriate deadline. Requests to delay submission of documents, scheduled for review by The Commission Board of Trustees, may be granted in extraordinary circumstances and then only by formal request to and approval by the President of The Commission. Circumstances that may merit consideration include delay in receipt of audited financial statements, or natural disaster or other catastrophic event significantly disrupting the institution’s operations. See The Commission policy, Requests for a Period of Noncompliance for additional information.

Documents should be submitted in an electronic format. Electronic submission requirements and helpful suggestions are provided in Appendix A.

An institution facing significant barriers to submitting a document electronically may request an exception from The Commission President allowing submission of the report in print format. Such a request must be made in writing to The Commission President at least ninety (90) days prior to the submission deadline.

General Useful Information

1. Provide a clear, complete, and concise report. If documentation is required, ensure that it is appropriate to demonstrating fulfillment of the requirement. Specify actions that have been taken and document their completion. Avoid vague responses indicating that the institution plans to address a problem in the future. If any actions remain to be accomplished, the institution should present an action plan, a schedule for accomplishing the plan, and evidence of commitment of resources for accomplishing the plan.
2. When possible, excerpt passages from text and incorporate the narrative into the report. Provide definitive evidence, not documents that only address the process (e.g., do not include copies of letters or memos with directives).
3. When possible and appropriate, provide samples of evidence of compliance rather than all documents pertaining to all activities associated with compliance.
4. Reread the report before submission and eliminate all narrative that is not relevant to the focus of the report. Ensure that all devices are virus free and have been reviewed for easy access by reviewers external to your institution.

[Compliance Certification]

Accreditation Committee. Institutions seeking initial Accreditation will submit a Compliance Certification – including narrative and supporting documentation – addressing their compliance with all the standards in the Principles of Accreditation except Standard 7.2 (Quality Enhancement Plan). The Compliance Certification should be uploaded no later than six (6) weeks before the start of the Committee’s visit. For further information, see The Commission Handbook for Institutions Seeking Initial Accreditation.

Off-Site Reaffirmation Committee. Institutions seeking Reaffirmation of Accreditation will submit a Compliance Certification – including narrative and supporting documentation – addressing their compliance with the standards in the Principles of Accreditation. The deadlines for submission of the Compliance Certification may be found in the “Timelines for Reaffirmation Tracks…” on The Commission website.

Presentation of the Compliance Certification

Institutions should use the template for the Compliance Certification found on the Institutional Resources page of The Commission website. Institutions should upload their report via The Commission Institutional Portal by the deadline for submission. The following documents should also be included as part of their uploaded file:

• An instruction document which contains clear directions on how to access the electronic documents.
• A current “Institutional Summary Form Prepared for The Commission Reviews” (PDF)
• An organizational chart
• Current Catalog(s)
• The institution’s most recent audit and any accompanying correspondence (PDF)

[Focused Report]

In preparation for the visit of the On-Site Reaffirmation Committee, institutions have the option of submitting a Focused Report addressing the preliminary findings of the Off-Site Reaffirmation Committee. Institutions should upload their narrative and supporting documentation via The Commission Institutional Portal no later than six (6) weeks prior to the start of the visit. Institutions should also include the following documents as part of their uploaded zipped file:

• An instruction document which contains clear directions on how to access the electronic documents.
• A current “Institutional Summary Form Prepared for The Commission Reviews” (PDF)

[Quality Enhancement Plan]

All institutions must submit a Quality Enhancement Plan document for review by the On-Site Reaffirmation Committee. Institutions should upload a zipped (compressed) file containing their narrative and supporting documentation via The Commission Institutional Portal no later than six (6) weeks prior to the start of the visit.

The QEP should be clear, succinct, and presented in a reader-friendly font. It may not exceed one hundred pages of size 11 Times New Roman font, including a narrative of no more than seventy-five pages and appendices of no more than twenty-five pages. A page header, right aligned, should identify the institution; the footer, centered, should indicate the page number. The title of the QEP, the name of the institution, and the dates of the On-Site Review should be prominently displayed on the title page. Institutions may organize QEPs in whatever format best conveys the ideas of the project and addresses all the components of the standard.

[Documentation for an Interim Off-Campus Instructional Sites Committee Review]

In preparation for notifying institutions regarding their upcoming Fifth-Year Interim Review, The Commission staff will determine the number of new Off-Campus Instructional Sites (sites offering 50% or more of an educational program) that have been approved since the institution’s most recent comprehensive visit. If that number is five (5) or more, the institution will be required to host an Interim Off-Campus Instructional Sites Committee. That committee will conduct visits to a sampling of the institution’s new sites. Institutions will work with their The Commission Vice President to schedule the visit, usually in the fall for Track A institutions or in the spring for Track B institutions. Six (6) weeks before the visit of the Interim Off-Campus Instructional Sites Committee, institutions should upload the appropriate Documentation for an Interim Off-Campus Instructional Sites Committee Review via The Commission Institutional Portal.

[Documentation for a Substantive Change Committee Review]

By The Commission policy, some types of substantive changes (e.g., Branch Campus, Merger/Consolidation, or Level Change) will require a Substantive Change Committee’s visit to review the institution’s ongoing compliance with the Principles of Accreditation within six months following the implementation of the change. Other types of substantive change may result in a Substantive Change Committee’s review being authorized, depending on the type of change and the nature of the institution. Six (6) weeks before the visit of the Substantive Change Committee, institutions should submit the appropriate Documentation for a Substantive Change Committee Review via The Commission Institutional Portal. The institution should choose the appropriate template from those available on the The Commission website.

[Fifth-Year Interim Report]

Member institutions are required to submit a Fifth-Year Interim Report for review by the Fifth-Year Interim Committee. This Report is submitted a little more than four years prior to an institution’s next scheduled reaffirmation. Institutions are notified by letter regarding the timing and requirements of their Fifth-Year Interim Report; general information (including a timeline by reaffirmation class) may be found on The Commission on Colleges and Universities’s website. Institutional representatives responsible for preparing and submitting the Fifth-Year Interim Report should follow carefully the instructions contained in the letter from The Commission and those found in the Template for the Fifth-Year Interim Report.

Institutions should submit their Fifth-Year Interim Report narrative and supporting documentation as a single zipped (compressed) file via The Commission Institutional Portal. Institutions should also include a document which contains clear instructions on how to access the electronic documents.

[Substantive Change Submissions]

Member institutions may be required to submit an application or prospectus to seek approval of a substantive change (see The Commission Substantive Change Policy and Procedures). Depending on the nature of the substantive change submission, these documents will be reviewed by The Commission staff members or The Commission Board of Trustees.

The institution should follow the instructions found in The Commission Substantive Change Policy and Procedures. Some substantive change submissions will also require reference to other relevant The Commission policies.

An institution’s prospectus or application should be submitted in compliance with calendar deadlines articulated in The Commission Substantive Change Policy and Procedures. Institutions should upload their submission through the Substantive Change portion of The Commission Institutional Portal.

[Institutional Special Reports]

Definition. This type of Report addresses the institution’s ongoing compliance with one or more standards of the Principles of Accreditation identified during a review of a formal written complaint or unsolicited information (See The Commission Policies Complaint Procedures Against The Commission or Its Accredited Institutions and Unsolicited Information).

Reviewers. The Institutional Special Report is initially reviewed by The Commission staff member assigned to the institution. That review may determine that there is sufficient evidence of the institution’s compliance with the standards in question and close the case. If, however, the review cannot find sufficient evidence to determine compliance, The Commission President may authorize a Special Committee to visit the institution and review ongoing compliance with the relevant standards. The Special Committee’s Report and the Institutional Special Report would subsequently be reviewed by The Commission Board of Trustees. Finally, The Commission President may choose to forward the Institutional Special Report directly to the Board of Trustees. In either of these two last eventualities, the report is subject to the review procedures of The Commission’s standing committees, including the initiation of a monitoring period, the imposition of a sanction, or a change of accreditation status.

Report Presentation. Structure the response so that it addresses the concerns described in the letter from The Commission in the order that they appeared. For each standard cited, (1) restate the number of the Core Requirement or Standard exactly as it appeared in the letter; (2) cite verbatim the current request of The Commission that is related to the standard cited (reference notification letter from The Commission); and (3) prepare a response to the finding. Institutions should submit their Institutional Special Report narrative and supporting documentation as a single zipped (compressed) file via The Commission Institutional Portal.

Due Date. The Report is due on the date specified in the letter sent by The Commission. If a Special Committee has been authorized to visit the institution, the Report will be due to every member of the Committee and The Commission staff member no later than four (4) weeks before the start of the visit. Requests for extensions to the date must be made to The Commission President at least two weeks in advance of the original due date. (See The Commission policy Deadlines for Reports and Profiles.)

[Response Report to the Visiting Committee]

Any On-Site Reaffirmation Committee, Interim Off-Campus Instructional Sites Review Committee, Substantive Change Committee, or Special Committee may propagate recommendations, if it determines that the institution under review has not demonstrated compliance with one or more of the Principles of Accreditation. In preparation for review by The Commission Board of Trustees, the institution should submit a Response Report addressing each recommendation included in the Committee’s Report. A formal Transmittal Letter will be included with the Committee’s Report transmitted from The Commission Vice President’s office to the institution’s Chief Executive Officer. This Transmittal Letter provides vital information regarding the institution’s Response Report, including the due date of the submission.

Definition. A Response Report addresses the findings of a visiting committee. It provides updated or additional documentation regarding the institution’s compliance with the Principles of Accreditation.

Reviewers. The Response Report, along with the Committee Report and other documents, is reviewed by The Commission Board of Trustees and is subject to the review procedures of The Commission’s standing committees, including the initiation of a monitoring period, the imposition of a sanction, or a change of accreditation status.

Report Presentation. Structure the response so that it addresses committee recommendations in the order that they appear in the report. For each recommendation, provide the number of the Core Requirement or Standard and state the recommendation exactly as it appears in the visiting committee report. Describe the committee’s concerns that led to the recommendation by either summarizing the concerns or inserting verbatim the complete narrative in the report pertaining to the recommendation. Provide a response with documentation.

Due Date. The Response Report is due on the day indicated in the transmittal letter from The Commission staff accompanying the visiting committee report. The institution should upload its Response Report as a single zipped (compressed) file via The Commission Institutional Portal.

[Referral Report]

Definition. This report addresses continued concerns of compliance identified by the Committee on Fifth-Year Interim Reports and referred to The Commission Board of Trustees.

Reviewers. The Referral Report is reviewed by The Commission Board of Trustees and is subject to the review procedures of The Commission’s standing committees, including the initiation of a monitoring period, the imposition of a sanction, or a change of accreditation status.

Report Presentation. Structure the response so that it addresses the concerns described in the letter from The Commission President in the order that they appeared. For each standard cited, (1) restate the number of the Core Requirement or Standard exactly as it appeared in the letter; (2) cite verbatim the current request of The Commission that is related to the standard cited (reference notification letter from the President of The Commission); and (3) prepare a response to the finding.

Due Date. The Referral Report is due on the date specified in the notification letter sent by The Commission President. Requests for extensions to the date must be made to the President at least two weeks in advance of the original due date. (See The Commission policy Deadlines for Reports and Profiles.) The institution should upload its Referral Report as a single zipped (compressed) file via The Commission Institutional Portal.

[Follow-Up Report]

Definition. Some member institutions are asked to submit a Follow-Up Report at during the same period as their Fifth-Year Interim Report will be reviewed. This report addresses ongoing compliance with one or more standards of the Principles of Accreditation, and institutions are usually asked to submit such a report when they encountered significant difficulties documenting compliance during their previous review.

Reviewers. The Follow-Up Report is reviewed by The Commission Board of Trustees and is subject to the review procedures of The Commission’s standing committees, including the initiation of a monitoring period, the imposition of a sanction, or a change of accreditation status.

Report Presentation. Structure the response so that it addresses the concerns described in the letter from The Commission President in the order that they appeared. For each standard cited, (1) restate the number of the Core Requirement or Standard exactly as it appeared in the letter; (2) cite verbatim the current request of The Commission that is related to the standard cited (reference notification letter from the President of The Commission); and (3) prepare a response to the finding.

Due Date. The Fifth-Year Follow-Up Report is due on the date specified in the letter from The Commission President requesting the Report (usually on the date Monitoring Reports are due for that meeting of The Commission Board of Trustees). Requests for extensions to the date must be made to the President no later than two weeks in advance of the original due date. (See The Commission policy Deadlines for Reports and Profiles.) The institution should upload its Follow-Up Report as a single zipped (compressed) file via The Commission Institutional Portal.

[Monitoring Report]

Definition. This Report addresses recommendations and continued concerns of compliance usually identified by the Committee on Compliance and Reports (C&R) or by the Executive Council and referred to The Commission Board of Trustees. It follows the C&R Committee’s review of an institution’s response to a visiting committee report.

Reviewers. The Monitoring Report is reviewed by The Commission Board of Trustees and is subject to the review procedures of The Commission’s standing committees, including the continuation of a monitoring period, the imposition of a sanction, or a change of accreditation status.

Report Presentation. Structure the response so that it addresses committee recommendations in the order that they appeared in the report. For each recommendation, (1) restate the number of the Core Requirement or Standard, the number of the recommendation, and the recommendation exactly as it appeared in the visiting committee report; (2) provide a brief history of responses to the recommendation if more than a first response (to include an accurate summary of the original concerns of the visiting committee, a summary of each previous institutional response and an explanation of what had been requested by The Commission); (3) cite verbatim the current request of The Commission that is related to the recommendation (reference notification letter from the President of The Commission); and (4) prepare a response to the recommendation.

Due Date. The Monitoring Report is due on the date specified in the notification letter sent by The Commission President. Requests for extensions to the date must be made to the President at least two weeks in advance of the original due date. (See The Commission policy Deadlines for Reports and Profiles.) The institution should upload its Monitoring Report as a single zipped (compressed) file via The Commission Institutional Portal.

For any report requested for review by The Commission Board of Trustees, an institution should prepare a title page that includes the following:

1. Name of the institution
2. Mailing address of the institution
3. Dates of the committee visit (not applicable for the Referral Report or Fifth-Year Follow-Up Report)
4. The type of report submitted
5. Name, title, and contact information for the person(s) preparing the report