CAA Policies and Procedures Manual Nov 2020

Policies and
Procedures
Manual
Commission for Academic Accreditation
Ministry of Education
United Arab Emirates
December 2019
59
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Table of Contents
1. INTRODUCTION AND BACKGROUND ............................................................................................................................. 6
RATIONALE.................................................................................................................................................................. 6
METHODOLOGY .......................................................................................................................................................... 6
HISTORICAL OVERVIEW .............................................................................................................................................. 7
VISION, MISSION, CORE VALUES, STRATEGIC GOALS ................................................................................................. 8
ORGANIZATION AND GOVERNANCE........................................................................................................................... 9
STRATEGIC PLANNING .............................................................................................................................................. 10
POLICIES AND PROCEDURE ....................................................................................................................................... 11
PREFACE FOR POLICIES ............................................................................................................................................. 11
2. ACCREDITATION POLICIES AND PROCEDURES FOR INSTITUTIONS ............................................................................. 12
STANDARDS FOR LICENSURE AND ACCREDITATION ................................................................................................. 12
STANDARDS FOR LICENSURE AND ACCREDITATION OF TECHNICAL & VOCATIONAL EDUCATION & TRAINING ..... 12
E-LEARNING STANDARDS FOR LICENSURE AND ACCREDITATION ............................................................................ 13
PROCEDURAL MANUALS FOR INITIAL INSTITUTIONAL LICENSURE, RENEWAL OF INSTITUTIONAL LICENSURE,

INITIAL PROGRAM ACCREDITATION, AND RENEWAL OF PROGRAM ACCREDITATION. ................................ 13
PROCEDURES FOR INSTITUTIONAL LICENSURE AND PROGRAM ACCREDITATION FOR FOREIGN BRANCH
CAMPUSES ..................................................................................................................................................... 14
GRADUATE EDUCATION ADMISSION REGULATIONS FOR LICENSED INSTITUTIONS ................................................ 14
CRITERIA FOR TEACHING HOSPITALS AND MEDICAL / CLINICAL FACULTY ............................................................... 14
TEACH OUT POLICY FOR CLOSED INSTITUTIONS OR PROGRAMS ............................................................................. 15
COMPLAINTS AGAINST INSTITUTIONS ...................................................................................................................... 15
APPEALS POLICY........................................................................................................................................................ 16
JOINT REVIEWS WITH OTHER QUALITY ASSURANCE AGENCIES ............................................................................... 17
POLICY ON CHANGE OF OWNERSHIIP OR CONTROL OF AN INSTITUTION ............................................................... 18
FINANCIAL MATTERS RELATING TO INSTITUTIONS .................................................................................................. 18
SPECIAL VISITS TO INSTITUTIONS ............................................................................................................................. 18
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3. POLICIES AND PROCEDURES FOR COMMISSION WORK WITH EXTERNAL REVIEW TEAMS ....................................... 20
PRE-VISIT ACTIVITIES: RECEIPT OF APPLICATIONS ................................................................................................... 20
PRE-VISIT ACTIVITIES: DETERMINING ERT ............................................................................................................... 20
FORMS ASSOCIATED WITH THE PROCESSES OF REVIEWS ........................................................................................ 20
HANBOOK FOR EXTERNAL REVIEW TEAMS .............................................................................................................. 21
CONFLICT OF INTEREST ............................................................................................................................................. 22
HONORARIA POLICY FOR ERTS ................................................................................................................................. 22
TRAVEL ARRANGEMENTS FOR ERTS ......................................................................................................................... 22
REPORT WRITING...................................................................................................................................................... 23
4. COMMISSION ADMINISTRATIVE PROCEDURES ........................................................................................................... 24
ETHICAL OBLIGATIONS OF COMMISSIONERS AND COMMISSION STAFF ................................................................. 24
COMPLAINTS AGAINST THE COMMISSION ............................................................................................................... 24
INSTITUTIONAL LICENSURE AND PROGRAM ACCREDITATION PROCEDURES .......................................................... 24
BUDGETING AND FINANCE ....................................................................................................................................... 25
PROFESSIONAL DEVELOPMENT ................................................................................................................................ 25
CONSULTING ............................................................................................................................................................. 25
DOCUMENT CONTROL, MANAGEMENT, CONFIDENTIALITY, AND DISPOSITION ..................................................... 25
HEALTH AND SAFETY POLICY .................................................................................................................................... 26
RISK MANAGEMENT POLICY ..................................................................................................................................... 26
SIGNING AUTHORITY ................................................................................................................................................ 27
5. PERSONNEL POLICIES AND PROCEDURES .................................................................................................................... 28
VACANT POSITIONS .................................................................................................................................................. 28
ORIENTATION OF NEW COMMISSIONERS ................................................................................................................ 28
WORKING HOURS/ HOLIDAYS .................................................................................................................................. 29
POSITION DESCRIPTIONS .......................................................................................................................................... 29
ANNEXES ........................................................................................................................................................................... 31
ANNEX 1 Initial Accreditation Process ............................................................................................................... 32
ANNEX 2 Renewal of Accreditation Process ...................................................................................................... 33
ANNEX 3 Initial Licensure Process ...................................................................................................................... 34
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ANNEX 4 Renewal of Licensure Process ............................................................................................................. 35
ANNEX 5 Substantive Change Process ............................................................................................................... 36
ANNEX 6 CAA Strategic Plan 2020-2024 ............................................................................................................ 37
ANNEX 7 Council of Commissioners (COC) ........................................................................................................ 42
APPENDICES ...................................................................................................................................................................... 44
APPENDIX 1: CAA ORGANIZATIONAL CHART ....................................................................................................... 45
APPENDIX 2: CAA POSITION DESCRIPTIONS ........................................................................................................ 46
APPENDIX 3: STRATEGIC ADVISORY COMMITTEE ............................................................................................... 59
APPENDIX 4: CRITERIA FOR TEACHING HOSPITALS ............................................................................................. 60
APPENDIX 5: TEACH OUT ..................................................................................................................................... 65
APPENDIX 6: COMPLAINTS .................................................................................................................................. 69
APPENDIX 7: CHANGE OF OWNERSHIP OR CONTROL OF AN INSTITUTION ........................................................ 71
APPENDIX 8: RECEIPT OF APPLICATIONS ............................................................................................................. 73
APPENDIX 9: DETAILS OF ERT SELECTION, SITE VISIT ACTIVITIES, COMMISSIONERS AND REPORTS .................. 74
APPENDIX 10: CAA FORMS .................................................................................................................................... 80
APPENDIX 11: GUIDE FOR ERT MEMBERS .......................................................................................................... 134
APPENDIX 12: PROCEDURES .............................................................................................................................. 149
APPENDIX 13: ENTITLEMENTS OF ERTS............................................................................................................... 153
APPENDIX 14: ERT REPORT TEMPLATE ............................................................................................................... 154
APPENDIX 15: AGENDA TEMPLATE ..................................................................................................................... 159
APPENDIX 16: ETHICAL OBLIGATIONS OF COMMISSIONERS AND COMMISSION STAFF .................................... 163
APPENDIX 17: DOCUMENT CONTROL, MANAGEMENT, CONFIDENTIALITY AND DISPOSITION ......................... 166
APPENDIX 18: DESCRIPTION OF THE CORE ......................................................................................................... 169
APPENDIX 19: PUBLIC INFORMATION AVAILABLE ON THE CAA WEBPAGE ........................................................ 170
APPENDIX 20: DOCUMENT CONTROL AND MANAGEMENT ............................................................................... 171
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1. INTRODUCTION AND BACKGROUND
RATIONALE
The purpose of this Manual is the establishment of a reference document containing all the policies
and procedures established by the Commission for Academic Accreditation (hereafter CAA or
Commission). The CAA has a number of policies and procedures governing the process by which
an institution seeks institutional licensure or program accreditation. In addition, there are numerous
internal policies and procedures related to processing applications from institutions as well as office
administration and operations.
A hallmark of successful quality assurance processes is transparency. It is a fundamental principle

of sound management policy that transparency and integrity are inextricably linked. In general, the
most successful organizations; be they commercial businesses, financial institutions, governments,
or academic institutions; demand a high level of integrity, both within the organizations themselves
and in their relations with the people they serve. In this regard, most national and local Quality
Assurance (QA) organizations place integrity high on the list of standards. The institution that
certifies US QA agencies, for example, is called the National Advisory Committee on Institutional
Quality and Integrity. The Commission places integrity at the top of its list of Core Values and
Guiding Principles.
A key to achieving the goal of integrity is to maintain transparency. That is, just as the Commission
requires that institutions be straight forward and transparent in their dealings with the Commission
and with students, parents, external and internal stakeholders, faculty, and staff, the Commission
demands no less of itself.
One important means for achieving transparency is to maintain Commission policies and
procedures in the public domain and to allow open access to them. In order to accomplish this
objective, it is necessary to have them formulated in writing, organized, and appropriately indexed.
METHODOLOGY
First, the methodology used to develop the Manual is similar to the policy which guides licensed
institutions, that is, an institution’s Policies and Procedures Manual must contain “all the official
policies, procedures, and regulations of the institution.” For the Commission those policies are a
combination of internal administrative policies, policies that define the Commission’s interaction
with institutions, policies with regard to the Commissioners and policies with regard to the External
Review Teams. In this regard, a number of Commission policies previously published —notably
accreditation policies and procedures and some procedures providing internal guidance for
Commissioners or External Review Teams (ERTs)—are referenced in the Manual and are also
available on the CAA website (http://www.caa.ae).
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Second, as guidance for the process, the Commission has benefited from a review of the policies
and procedures of other Quality Assurance (QA) agencies and organizations in the US, South
America, UK, Australia, New Zealand, Europe, and the Gulf region. As might be expected, some
organizations have more complete listings than others. In many cases, the QA agencies only list on
their websites those policies directly related to institutional licensing and accreditation processes.
Some have only limited listings of other policies.
The most useful, for the Commission’s purposes, were the listings by four of the US regional
accrediting agencies— the Middle States Commission on Higher Education (MSCHE), the North
Central Commission on Higher Learning (NCCHL), the Southern Association of Colleges and
Schools Commission on Colleges (SACSCOO), and the New England Association of Schools and
Colleges (NEASC). To a considerable extent, the organization and presentation of policies and
procedures by these organizations served as a guideline to the organization of this manual.
Third, the Policies and Procedures Manual of the Commission is a living document. Policies will
be regularly reviewed and ensuing changes to one or more of the policies contained in this document
will be documented accordingly. All documents will indicate the date of last revision and every
effort will be made to keep the Policies and Procedures Manual current. After review and
approval, a copy of the Manual will be made available to all members of the Commission staff in
both e-copy and hard copy.
HISTORICAL OVERVIEW
The Commission was established by the Minister of Higher Education and Scientific Research in
the year 2000. The CAA is now located within the UAE’s federal Ministry of Education (hereafter
the Ministry or MoE – formerly the Ministry of Higher Education and Scientific Research –
MoHESR, up to February 2016). The authority to license federal and non-federal educational
institutions to grant degrees and other academic awards, and to accredit their programs, rests with
the Ministry, and the Commission has the responsibility of discharging that authority.
In the UAE, any federal or non-federal (private) institution that provides regular, theoretical,
practical, or applied curricula of one academic year or longer beyond the UAE Secondary School
Certification (or its equivalent), and that leads to an academic degree, certificate, or diploma, must
be licensed and have its programs accredited in order to be officially recognized by the Ministry.
The quality assurance processes described in this Manual are implemented across all institutions,
and its programs.
The number of licensed institutions has increased dramatically from 2000 when the CAA was
established. Similarly, the number of accredited programs has increased exponentially. Currently
the number of licensed institutions is over 80 and the number of accredited programs now exceeds
1200. Many of these are expected to require renewal of accreditation in the coming 4-5 years,
added to an almost equal number of proposed new programs expected to be submitted for Initial
Accreditation.
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VISION, MISSION, CORE VALUES, STRATEGIC GOALS
Vision
To provide leadership by upholding quality assurance standards that promote distinction,
innovation and academic excellence within higher education.
Mission
To work collaboratively with stakeholders to assure the quality, effectiveness and continuous
improvement of higher education, safeguard its system, embrace its diversity and foster the quality
culture.
Core Values – ACCREDITS

A: Accountability
We are accountable to the Ministry of Education and to the people of the UAE.
C: Collaboration
We work in a spirit of collaboration and partnership with Higher Education institutions.
C: Communication
We communicate clearly, accurately, and fully with partners and stakeholder and seek and
welcome their feedback
R: Responsiveness
We are responsive to the evolving needs of the higher education sector and its stakeholders
E: Excellence
We aim to achieve the highest standards in what we do and to encourage institutions to meet
their ambitions at the highest level
D: Diversity
We embrace diversity in the provision of higher education
I: Integrity
We adhere to established standards, policies and procedures and to established professional
ethics in all that we do.
T: Transparency
We are transparent in all our activities while respecting each institution’s confidentiality.
S: Sustainability
We are committed to sustainable practices.
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Strategic Goals
1. Provide institutional licensure and program accreditation services using contemporary and
internationally inspired Standards and efficient procedures that accommodate the expanding and
diverse higher education landscape in the UAE.
2. Foster capacity building activities and a creative work environment within the Commission to
further enhance its efficiency and effectiveness.
3. Cultivate an organizational culture that is based on a robust internal quality assurance system and
inter-organizational collaboration with federal and local regulatory bodies.
4. Adopt collaborative practices with other accreditation and education agencies to improve
accreditation, to promote effective quality assurance processes and to share best practices.
5. Advance the role of the Commission as a respected international leader of quality enhancement
in higher education.
ORGANIZATION AND GOVERNANCE
Establishment Decree
The CAA was established in August 2000, through a decree from H.E. the Minister of Higher
Education and Scientific Research and, as part of MoHESR, reporting directly to the Minister. Due
to transitions at the Ministry level, CAA now reports directly to the Minister of Education (MoE).
Organization Chart
As depicted in the organization chart, ultimate authority over the CAA rests with the Minister of
Education (MoE). A Strategic Advisory Committee provides advisory guidance regarding policies
and procedures related to administration and organization of the Commission office, and the
licensing and accreditation procedures for the UAE’s higher education institutions.
All officers of the Commission report to the Director, who is responsible for the day to day
management of the Commission. The Director reports to the Minister of Education, and coordinates
with the Undersecretary of the MoE.
Recommendations to the Minister regarding licensure and accreditation decisions are made by the
Commissioners and the Director, acting collectively as the Council of Commissioners (see Annex
7 for more details). A current Organization Chart is provided as Appendix 1.
Section 5 of the Manual presents CAA personnel policies and procedures. A list of the current
positions and their descriptions are provided in Appendix 2
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STRATEGIC PLANNING
The CAA’s first comprehensive Strategic Plan was developed in 2008, covering the 5-year planning
period 2008—2012, and includes implementation details. It comprised several components:
 The CAA’s Purpose: its Mission, its Goals and those Values and Guiding Principles that
characterize and govern its operation.
 The CAA’s Strategic Goals and Objectives.
Following a number of internal meetings to consider the CAA’s Mission Statement, a retreat was
used to develop the detail of the Strategic Plan. A comprehensive SWOT analysis was prepared
and used to inform the planning process. The draft Strategic Plan was refined over subsequent
weeks and published for internal use, with a shorter version made accessible to the public on the
CAA’s website. Please see Appendix 19 for full list of material on the CAA’s website. A
comprehensive review of progress in implementation of the Strategic Plan was carried out in 2010.
A process was initiated in 2012 to review the CAA’s Strategic Plan (2008 – 2012) and provide
succession in the planning process and implementation. However, the pending changes in the
relationship with the Ministry, and the merger of the two ministries (MoE and MoHESR), along
with proposed changes to Financial Regulations and Human Resource policies and practice,
indicated that the planning process should be delayed until clarity was obtained on some key
operational matters.
The CAA Mission Statement and Strategic Plan have been reviewed and updated in 2016 then again
in 2019 and now incorporate the revisions resulting from that internal review.
CAA Strategic Plan 2020 - 2024
The Commission’s Strategic Plan 2020-2024, of which a copy is provided in Annex 6, provides a
framework and direction for organizational planning and operations. As stated in the Plan, there is
a central goal to ensure quality and academic standards in higher education in the UAE. To this
end, the CAA aims to maintain and further develop its quality framework so that institutions of
higher education in the UAE operate in line with international academic, administrative, managerial,
and operational standards.
Strategic Advisory Committee
The CAA Strategic Advisory Committee, comprised of accreditation, quality assurance, and higher
education experts, is established to review on regular basis CAA’s current practices on licensure
and accreditation and recommend best practices for CAA to utilize. The main function of the
committee is to provide strategic advice to the CAA that is related to the goals and objectives of the
CAA. Details of the Strategic Advisory Committee can be found in Appendix 3.
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POLICIES AND PROCEDURE
The Commission has developed policies and procedures governing all matters relating to its duties,
responsibilities, operations, and licensing and accrediting activities. With recent changes to the
organizational structure of the Ministry, the Commission is now more integrated within the
Financial Policies and Regulations of the MoE, and also to the Ministry’s Policies regarding
management of Human Resources.
Dating of Policies
With the exception of the first adoption of a body of policies or the subsequent adoption of major
revisions, which will carry the date for the complete set of policies or revisions, each policy carries
a date of adoption and any revisions. Policies are effective as of the date of adoption which is the
date on which the Minister of Education signs an authorization indicating his approval. See
Appendix 20 for the information on the date of revision of policies included in this manual.
Review and Revision
The Commission recognizes that higher education is rapidly changing and that the policies and
procedures contained herein need to reflect those changes. Therefore, the Commission commits to
regularly review its policies and procedures, particularly those related to institutional dynamics and
change, to evaluate their responsiveness to the higher education environment, their effectiveness in
providing quality assurance, and their usefulness in enhancing institutional and educational
improvement.
PREFACE FOR POLICIES
In the following policy sections, there is a statement of scope as well as a statement of purpose for
each individual policy. More detail on the policy and associated procedures may be further described
in a referenced appendix. Those documents available on the CAA website are so noted.
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2. ACCREDITATION POLICIES AND PROCEDURES FOR
INSTITUTIONS
STANDARDS FOR LICENSURE AND ACCREDITATION
Scope
The scope of the regulations for licensure and accreditation covers all institutions of higher
education in the United Arab Emirates, including all federal and non-federal colleges and
universities and branch campuses of foreign entities offering postsecondary regular, theoretical,
practical, or applied curricula leading to graduate or undergraduate degrees, diplomas, or certificates
of one year or more in duration. Training programs offered by public or private organizations which
are not colleges or universities and do not lead to the award of a degree, diploma, or certificate are
not covered by these policies. The Standards 2019 provide the threshold requirements that an
institution must meet for licensure and accreditation. Institutions located in the free zones of Dubai
and RAK are eligible to apply for licensure and subsequent accreditation of their programs, but are
not required to do so. Credentials earned from non-licensed institutions in the UAE will not be
attested by the MoE and are thus valid only in the Emirate where received.
Purpose
The Standards 2019 were developed by the Commission to guide institutions in establishing high
quality programs and to assure prospective students, their families, employers, and other interested
parties that UAE’s colleges and universities meet standards of quality consistent with current
international practice and professional judgment.
STANDARDS FOR LICENSURE AND ACCREDITATION OF TECHNICAL &

VOCATIONAL EDUCATION & TRAINING
Scope
The Commission has an obligation to ensure that all Vocational Education and Training (VET)
institutions have the guidance, assistance, and regulatory monitoring to ensure the development of
high quality programs that will enable their students to acquire the knowledge and skills required in
the workplace.
The regulations for licensure and accreditation of technical and vocational institutions and programs
apply to all institutions in the United Arab Emirates that offer postsecondary vocational education
and training programs and offer diplomas, certificates, or other academic awards of one year or
more.
Purpose
To provide guidance to Vocational and Educational Training institutions offering workplace

focused, competency-based education such that they can secure licensure of their institutions and
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accreditation of their programs using Standards 2019, which focus on the specific mission and
instructional approach of these institutions.
E-LEARNING STANDARDS FOR LICENSURE AND ACCREDITATION
Scope
The scope of the regulations for licensure and accreditation of e-learning covers all institutions of
higher education in the United Arab Emirates, including all federal and non-federal colleges and
universities and branch campuses of foreign institutions offering postsecondary regular, theoretical,
practical, or applied curricula of one academic year or longer leading to graduate or undergraduate
degrees, diplomas, or certificates. These regulations govern institutions that offer a significant
portion of their educational programs through e-learning methodologies.
The e-Learning Standards were revised through both internal and external review and incorporated
as an appendix into the Standards, 2019. As of 2013, there is not a current separate and applicable
edition of these Standards.
Purpose
The e-Learning Standards for Licensure and Accreditation were developed by the Commission to
guide institutions in establishing high quality programs and to assure prospective students, their
families, employers, and other interested parties that UAE’s colleges and universities meet
standards of quality consistent with current international practice and professional judgment.
PROCEDURAL MANUALS FOR INITIAL INSTITUTIONAL LICENSURE, RENEWAL

OF INSTITUTIONAL LICENSURE, INITIAL PROGRAM ACCREDITATION, AND
RENEWAL OF PROGRAM ACCREDITATION.
Scope
The Procedural Manuals (2019) were developed to give guidance to institutions seeking initial
licensure, renewal of licensure, initial program accreditation, or renewal of program accreditation.
There is a separate Manual for each type of application. The Manuals include an overview of each
process and offer suggestions as to how to respond to each of the Standards. The Manuals were
designed for use by the institutions of the UAE and are a companion to the Standards. Institutions
using the Manuals should be made aware of the fact that the Manuals are not a substitute for
adhering to the Standards. The Procedural Manuals can be found on the CAA website
(http://www.caa.ac.ae).
Purpose
To aid institutions in developing applications for initial licensure, renewal of licensure, initial
accreditation, and renewal of accreditation.
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PROCEDURES FOR INSTITUTIONAL LICENSURE AND PROGRAM
ACCREDITATION FOR FOREIGN BRANCH CAMPUSES
Scope
All non-UAE institutions wishing to establish a branch campus in the UAE must comply with the
guidelines of both the local Emirate in which they locate and with the procedures of the
Commission. Local guidelines can be obtained from the offices of the local education authorities
(in Abu Dhabi, the Abu Dhabi Education Council; in Dubai, the Knowledge and Human
Development Authority). Guidelines for the Commission are incorporated into the Standards, 2019
edition. There are some circumstances (free zone institutions in Dubai, for example) in which an
institution is not required to apply for licensure and accreditation through the MoE. Qualifications
issued through non-licensed institutions cannot be attested by the MoE.
Purpose
To guide non-UAE institutions in the development of branch campuses in the UAE.
GRADUATE EDUCATION ADMISSION REGULATIONS FOR LICENSED

INSTITUTIONS
Scope
In order to bring consistency to the graduate program admission standards for institutions, the
Commission developed separate graduate admission guidelines. First promulgated as a separate
document, the guidelines are now incorporated into the Standards, 2019.
Purpose
To provide consistency in the requirements for admitting students to graduate programs at non-
federal institutions in the UAE.
CRITERIA FOR TEACHING HOSPITALS AND MEDICAL / CLINICAL FACULTY
Scope
These requirements complement the Commission regulations in the Standards for Licensure and
Accreditation and apply to all teaching hospitals/healthcare units and criteria for medical/clinical
faculty. The criteria can be found in Appendix 4
Purpose
The purpose of this policy is to provide regulatory guidance regarding the programs, operations,
services, clinical services, and patients of teaching hospitals/healthcare units and criteria for
medical/clinical faculty.
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TEACH OUT POLICY FOR CLOSED INSTITUTIONS OR PROGRAMS
Scope
A decision to close an educational program, branch campus, or the entire institution requires
thoughtful planning and careful consultation with all affected constituencies. Every effort should
be devoted to informing each constituency as fully as possible about the conditions compelling
consideration of a decision of such importance, and all available information should be shared. As
much as possible, the determination to close a program, branch campus, or the institution should be
made through a consultative process and only after alternatives have been considered, but
responsibility for the final decision to close rests with the board of trustees. Since the immediate
interests of current students and faculty are most directly affected, their present and future prospects
require especially sensitive and timely attention and involvement. For this reason, as a part of the
initial institutional accreditation process, CAA requires that institutions provide the Commission
with an Institutional or Program Closure and Teach out Plan.
Purpose
To guide institutions declaring an intent to close an institution and/or terminate a program in which
students are already enrolled but who are not yet finished with the program.
Teach out policy and procedures can be found in Appendix 5.
COMPLAINTS AGAINST INSTITUTIONS
Scope
The Commission recognizes the value of information provided by students, employees, and others
in determining whether an institution’s performance is consistent with the Commission’s standards
and expectations for accreditation. The Commission’s interest also is in assuring that member
institutions maintain appropriate grievance procedures and standards of procedural fairness and that
procedures are followed appropriately.
Individuals can submit at any time information regarding an institution’s compliance with
Commission eligibility requirements, standards, or policies or regarding an institution’s compliance
with its own policies or procedures. Individuals interested in submitting information regarding an
institution’s accreditability to be considered during an upcoming accreditation review should submit
that information to the Commission. The Commission reserves the right to review information
under either policy it determines to be appropriate under the circumstances.
The Commission’s complaint procedures are created to address non-compliance with the
Commission’s or the institution’s standards, policies, or procedures. They are not intended to be
used to involve the Commission in disputes between individuals and affiliated institutions, or to
cause the Commission to interpose itself as a reviewing authority in individual matters of admission,
grades, granting or transferability of credits, application of academic policies, fees or other financial
matters, disciplinary matters, contractual rights and obligations, personnel decisions, or similar
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matters. Nor does the Commission seek any type of compensation, damages, readmission, or any
other redress on an individual’s behalf. The Commission does not respond to, or take action on, any
complaint or allegation that is defamatory, hostile, or contains profanity.
The Commission expects individuals to attempt to resolve the issue through the institution’s own
published grievance procedures before submitting a complaint to the Commission. Therefore, the
Commission’s practice is not to consider a complaint that is currently in administrative proceedings,
including institutional proceedings, or in litigation. However, if the Commission determines that the
complainant raises issues that are so immediate that delay may put the institution’s accreditation in
jeopardy, or delay has the potential to cause harm to students or the campus community, the
Commission may, at its discretion, choose to proceed with the review.
Because of the need for information to be current, except in extraordinary circumstances, the
Commission will not consider complaints if two years or more have passed since the complainant
initiated the institution’s grievance procedure.
Aggrieved individuals must submit complaints in writing and address them directly to the Director,
Commission for Academic Accreditation, Ministry of Education, P.O. Box 45253, Abu Dhabi,
UAE. The Commission will not review complaints that are not in writing or are anonymous. Those
submitting complaints must provide contact information for the Commission to follow-up. The
Commission also will not act on complaints that are submitted on behalf of another individual or
complaints which are forwarded to the Commission.
Purpose
To ensure accountability of licensed institutions in the UAE and to provide higher education
stakeholders with an opportunity to redress their concerns.
Details of Procedures can be found in Appendix 6
APPEALS POLICY
Scope
The policy applies to all institutions licensed by the Commission. Appeals are for matters related
to Commission actions regarding institutions or institutional programs. The Appeal process is not
applicable to students or other stakeholders wishing to appeal an institutional decision; such appeals
should be directed to and resolved through the institution itself.
Purpose
The Procedural Guidelines which were developed as companion pieces to the Standards, 2019 give
institutions the right to appeal an action of the Commission. Appeals are to be based on issues of
process and not on the substance of the Commission’s judgment. An appeal takes the form of a
letter submitted to the Director of the Commission.
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JOINT REVIEWS WITH OTHER QUALITY ASSURANCE AGENCIES
Scope
The Commission is open to joint reviews with other quality assurance agencies as appropriate. The
institution should propose the possibility of a joint review whenever there is overlap between the
international quality assurance body and that of the Commission. Such joint reviews might involve
an institution applying for re-licensure through the Commission and applying for affirmation of an
international accreditation such as that through Middle States or the Southern Association of
Colleges and Schools. Joint reviews might also include collaboration between the Commission and
a professional accrediting body such as ABET or AACSB when the institution is seeking
accreditation of a program and is also seeking accreditation of that program through an international
professional accreditor.
It is the policy of the Commission to:
• Work with recognized international accrediting bodies;
• Encourage MOU’s or letters of mutual understanding from such bodies;
• Encourage institutions to have Commission observers on all site teams which involve an
international accrediting body;
• Maintain the independence of the Commission such that the findings of an international
accrediting body will not substitute for those of the Commission. Collaborative visits will
result in two reports, one for the Commission which addresses the Standards and a second for
the collaborating agency.
Purpose
To state the CAA’s position and support for cooperation with other international accreditation
bodies.
Procedures
 An institution seeking an international accreditation should notify the Commission and agree
to a joint visit.
 The institution seeking an international accreditation should make the initial contact with its
international accreditor to inquire as to whether a joint visit is possible.
 The international accreditor can then contact the CAA to indicate whether or not it is willing
to engage in a joint visit and acknowledge that it will work with the CAA on the logistics of
said visit including the signing of MOU’s or letters of understanding as appropriate.
 The CAA, working with both the institution and the accreditor, will develop the logistics of
the joint visit to suit the mutual needs of the CAA, the institution and the international
accreditor.
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POLICY ON CHANGE OF OWNERSHIIP OR CONTROL OF AN INSTITUTION
Scope
There is a range of forms of ownership/control among the tertiary institutions of the UAE. These
range from those which are owned by a single individual, to those owned by a partnership, to those
which are part of a larger corporation, to those which are partially or wholly owned by the
government, be it an individual Emirate or the federal government. Ownership and/or control of
these institutions can change. Any change in ownership of an institution or a significant change in
the controlling body (the appointment of a new board of trustees, for example) is considered a
Substantive Change by the Commission. An institution considering a change in ownership must
submit a request for Substantive Change which adheres to the Standards for Licensure and
Accreditation, 2019, Stipulation 2.
Details of the policy can be found in Appendix 7
Purpose
To guide institutions when a change of ownership or control of an institution may occur.
FINANCIAL MATTERS RELATING TO INSTITUTIONS
Scope
Licensed institutions in the UAE work with the Commission and the MoE. This work involves
financial considerations for the processes associated with licensure and accreditation. In general,
there are no fees for Commission processes. For Licensure or Program Accreditation, the applicant
institution will be charged for the costs of any site visit to the institution including the travel
expenses of 2-3 external reviewers and their honorarium. Similarly, the institution bears the costs
associated with a site visit for audit or special reviews.
Purpose
To guide licensed institutions in the UAE regarding financial matters between the institutions and
the Commission.
SPECIAL VISITS TO INSTITUTIONS
Scope
The Commission for Academic Administration conducts a number of types of special visits to
institutions. Such special visits can be (a) at the invitation of the institution to help the institution
address an issue of the Standards; (b) at the request of the Minister of Education; (c) to follow-up
on issues raised during either licensure or accreditation activities; (d) to follow-up on complaints
received by the CAA. Special visits are scheduled in advance. The costs of special visits or audits
are borne by the institution. Following each special visit, the lead Commissioner files a summary
18
report on the visit which becomes part of the documentary record of the Commission and which
may be used for reporting to other federal offices of the UAE as needed.
Purpose
Special visits are designed to address “ad hoc” circumstances or situations arising at institutions
between formal visits for purposes of either licensure and/or accreditation.
19
3. POLICIES AND PROCEDURES FOR COMMISSION WORK
WITH EXTERNAL REVIEW TEAMS
PRE-VISIT ACTIVITIES: RECEIPT OF APPLICATIONS
Scope
The CAA receives a large number of applications which must be reviewed for completeness,
recorded, properly stored and information disseminated in an appropriate manner to ensure proper
handling.
Procedures for receipt of applications can be found in Appendix 8
Purpose
To describe the handling of all applications received by the CAA
PRE-VISIT ACTIVITIES: DETERMINING ERT
Scope
The CAA relies very heavily on a large number of subject matter specialists (some of whom also
serve as institutional reviewers). The subject matter specialists are listed in the “CORE” which is
regularly updated and to which Commissioners are expected to contribute the names and resumes
of potential reviewers. Please refer to Appendix 18 for description of CORE. The work with the
subject matter specialists (called External Review Teams) involves close collaboration with the
Commission staff with regard to travel, visit costs/honoraria and document provision/control or
follow-up. Thorough and advance preparation by the Commissioner and the members of the
External Review Team is essential to a successful quality assurance review.
Purpose
This policy is to ensure that External Review Team members are fully briefed and prepared for each
program review.
Detailed information can be found in Appendix 9
FORMS ASSOCIATED WITH THE PROCESSES OF REVIEWS
Scope
Throughout the processes described above, several forms help in documenting each step, ensuring
all required information is gathered, financial responsibilities to ERT are met and summary data is
available for entry into CORE. These forms are listed below:
Forms for the institution

 Form 09 Application for Initial and Renewal of Institutional Licensure
 Form 10 Application for Initial and Renewal of Program Accreditation
20
Forms used before a campus visit
 Form 05 ERT Conflict of Interest
 Form 13 Bank Details
 Form 14 Request for Transportation Service
 Form 15 Visit Details
Forms used during a campus visit

 Form 01 Institutional Risk Evaluation
 Form 03 ERT Visit Evaluation
 Form 04 Program Description
 Form 06 ERT Institutional Licensure Recommendation
 Form 07 ERT Program Accreditation Recommendation
It is optional to discuss these forms with input from the ERT

 Form 02 Quality Assurance Evaluation Metric
 Form 11 Program Compliance Indicator
Forms Used after a Campus Visit

 Form 12 Review Completion
Appeal Form
 Form 20 Appeal Form
Copies of all forms can be found in Appendix 10.
HANBOOK FOR EXTERNAL REVIEW TEAMS
Scope
The Handbook for External Review Teams is designed to provide international visitors with both
the broad outline of their work with the CAA and to offer specific guidance for everything from
travel, to local customs, to report writing.
Purpose
To provide ERT members with “how to do it” guidance for their work with the CAA.
Please see Appendix 11 for this Handbook
21
CONFLICT OF INTEREST
Scope
Reviewers working with the CAA are asked to determine whether there is any conflict of interest
such as a consulting arrangement, a pending or former application of employment or other
relationship with an institution which would preclude an independent, unbiased review of the
institution or program.
Purpose
The policy is to guide members of external review teams with regard to the considerations that must
be addressed with regard to a conflict of interest.
Please find detailed information in Appendix 12.
HONORARIA POLICY FOR ERTS
Scope
The Commission arranges travel for ERT members; travel costs are directly billed to the Ministry
who bills the Institution. Members of an ERT have full or half board at the hotel where they stay.
This is usually buffet breakfast and dinner. Lunch will be served at the institution.
Members of an ERT are paid an honorarium for the actual days of work in the UAE. Preparation
time prior to coming to the UAE is not included in the calculation of an honorarium; however, the
arrival day is counted. The honorarium will be transferred to the ERT member’s private bank
account in home country. Those individuals who are designated as the team chair receive an
additional day's honorarium for accepting and undertaking the responsibilities of the chair. The
typical honorarium is AED 2,000 per day with the usual site visit counted as 5 days for members, 6
days for Chair.
Purpose
To guide the Commission and ERT members on the financial arrangements for service as a member
of an ERT.
TRAVEL ARRANGEMENTS FOR ERTS
Scope
The Commission takes responsibility for making travel arrangements - both to/from the UAE and
within the UAE - for all members of External Review Teams. Travel is arranged through the CAA
Office and the Travel agent. Travel to/from the UAE is arranged by the most direct flight if at all
possible. Travel within the home country (from a local airport to an international airport, for
example) is economy class; international travel is business class. The CAA Travel Agent will work
22
with the individual traveler on any special arrangements including preferred airlines, extended stays
(at personal expense), etc. The CAA tries to meet the ERT members preferred carrier as well route
and dates, but this cannot be guaranteed. Extra days will not be reimbursed by the Commission.
Preferred travel routing may be accepted as long as it does not increase the cost.
Travel within the UAE is arranged by the CAA Office staff. This includes provision for travel
to/from the airport and travel from the hotel to the campus hosting the visit. The Commissioner
responsible for the visit will ensure that local travel meets the needs outlined in the agreed upon
schedule for a campus visit.
Entitlements of External Review Teams is given in Appendix 13.
Purpose
To guide ERT members regarding the arrangement of travel to/from the UAE and within the UAE.
REPORT WRITING
Scope
ERT members should collaborate on the report using the report template. Secretarial assistance is
not provided either by the Commission or by the campuses visited. Reports are generated in
Microsoft Word and should follow the template distributed in advance by the Commissioner. All
reports are in English unless otherwise specified by the Director or Commissioner at the time that
the visit is set up. Reports generated by the ERT should reflect a consensus of the members. The
Commissioner and the Director of the CAA have ultimate editorial authority on the reports since all
are submitted to the institution in the name of the Commission.
Purpose
To guide members of an ERT as to the accepted Commission practice for report writing.
Sample template for reports and visit schedules are given in Appendix 14 and Appendix 15
respectively.
23
4. COMMISSION ADMINISTRATIVE PROCEDURES
ETHICAL OBLIGATIONS OF COMMISSIONERS AND COMMISSION STAFF
Scope
Commissioners are professionals and adhere to the highest standards of ethical behavior expected
of professionals. In particular, Commissioners are expected to fully and collaboratively undertake
the tasks needed to perform their assigned duties, need to maintain confidentiality with regard to the
work of the Commission both internally and with the institutions which are served, need to engage
in appropriate professional growth and development, are accountable to the Director of the
Commission and ultimately to the Federal government of the UAE, are expected to adhere to UAE
laws in the work with External Review Teams, the handling of funds, and are to maintain accurate
records of financial transactions involving the money entrusted to them in the nature of their day to
day activities.
Purpose
To guide Commissioners as to the ethical expectations of their position.
Details concerning ethical obligations can be found in Appendix 16.
COMPLAINTS AGAINST THE COMMISSION
Scope
Complaints against the Commission are taken very seriously by the Ministry. The Commission will
not, however, respond to anonymous complaints. All complaints should be initially referred to the
Director of the CAA who will then take actions as appropriate. Complaints against individual
Commissioners or Staff will be handled as with other personnel matters and the utmost discretion
will be used. Complaints against the Commission as a governmental entity will be addressed
through appropriate investigation with follow-up action as needed. The specific procedures to be
followed will vary with the nature of the complaint. There will be a documentary record of the
follow through of the Commission regarding such complaints.
Purpose
To describe how complaints against the Commission will be viewed and handled.
INSTITUTIONAL LICENSURE AND PROGRAM ACCREDITATION PROCEDURES
Scope
The institutional licensure and program accreditation procedures of the Commission are outlined in
the Standards for Institutional Licensure and Program Accreditation (2019) and in the companion
volumes, Procedural Manuals.
24
Purpose
Procedures outlined in the Standards are designed to serve as the basis for all Commission actions,
including Initial Institutional Licensure, Renewal of institutional Licensure, Initial Program
Accreditation, and Renewal of Program Accreditation.
BUDGETING AND FINANCE
Scope
The CAA was established as the division within the MoE responsible for monitoring and regulating
private colleges and universities in the UAE. The MoE is responsible for managing all budgetary
matters for the CAA.
PROFESSIONAL DEVELOPMENT
Scope
The Commission is committed to and supportive of the professional development of the

Commissioners and Staff. Funds are included in the MoE budget to support all professional
development activities required for the Commissioner, Commission Staff.
CONSULTING
Scope
Consulting with institutions outside of the UAE is permissible with the knowledge and approval
of the Director.
Purpose
To guide Commissioners as to the expectations for undertaking consultancies outside the UAE.
DOCUMENT CONTROL, MANAGEMENT, CONFIDENTIALITY, AND DISPOSITION
Scope
The documentation provided to the Commission by institutions and the documentary record of the
Commission work with institutions is considered privileged information and should be treated with
appropriate confidentiality. Once an institution submits documentation to the Commission, it is
considered official and the property of the Commission subject to the scope of this policy. All
official documents are entered into the electronic archives of the Commission (known as the CORE)
and are accessible to Commissioners both in and out of the office. Documents may be reproduced
from the CORE on an “as needed” basis. Commissioners will often work with the paper documents
(as well as electronic files) in preparation for and in follow-up to a visit. Once a visit process is
complete (including the evaluation of responses), paper documents are turned back to office staff.
Paper documents of the Commission are stored in accord with guidelines established by the
Documents Coordinator in consultation with the Director. Generally speaking, paper documents
25
are not retained for more than five years at which time the documents are re-cycled. The electronic
file on the CORE is considered the permanent record of the Commission. The correspondence files
of the Commissioners (e-mail exchanges to/from evaluators, for example) are not considered official
documentation and are not retained other than by the Commissioner at his/her discretion.
Purpose
To guide the Commissioners and Commission staff with regard to the official documents of the
Commission.
HEALTH AND SAFETY POLICY
Scope
The Health and Safety of the employees of the Commission is of the utmost importance. The
Commission makes every effort to maintain a healthy and safe workplace. To that end, the
personnel policies affecting health and safety are applicable. The Commission, physically located
i n the MoE, a d h e r e s to the health and safety requirements set by the Ministry with regard
to the building. Employees are expected to participate in health and safety drills, understand
evacuation procedures and adhere to accepted good practice with regard to personal health and
safety.
Purpose
To guide employees with regard to basic health and safety considerations.
RISK MANAGEMENT POLICY
Scope
The CAA has developed specific risk management policies. In case of conflict, the laws, rules and
regulations of the UAE take precedence and are followed. Financial risks affecting the CAA occur
primarily in transactions related to Commission accreditation activities and CAA operations.
Operational risks usually involve a break down in the CAA’s internal controls and institutional
governance. Other operational risks include major failure of information technology systems or
natural disasters. The CAA’s internal controls and institutional governance are structured to
minimize operational risks. The MoE’s Office of Information Technology has implemented
policies and procedures intended to prevent the failure of Commission information systems and to
mitigate any potential loss that might occur.
Purpose
To describe commonly viewed risk for the CAA
26
SIGNING AUTHORITY
Scope
The CAA’s official policy is that no document requiring signature of a CAA official shall be signed
except by the CAA Director or only after the CAA Director’s explicit authorization. The CAA
Director is the signing authority for the CAA. No employee shall sign any document on behalf of
the CAA without the Director’s explicit authorization or by virtue of the CAA Director’s explicit
delegation of signing authority.
The director has designated a “back up” Commissioner who can be the co-signer of checks on those
occasions when the director is absent. Other requirements regarding financial matters and signatory
authority are covered under the budgetary policies presented elsewhere in this Manual.
Purpose
To guide Commissioners and Staff as to the appropriate protocols for the signing of official
documentation and/or all financial transactions.
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5. PERSONNEL POLICIES AND PROCEDURES
VACANT POSITIONS
Scope
The number of Commissioners and the number of staff are not fixed. The current organizational
chart is included in Appendix 1 and discussed in Section 1. The Director works closely with the
Minister to secure new positions, both Commissioners and staff, for the Commission. When a
vacancy occurs or when a new position is authorized, the director takes the lead in calling for
applications. The Council of Commissioners serves as a consultative body for the appointment of
new Commissioners.
Purpose
To guide the Commission and staff with regard to the filling of new and/vacant positions.
ORIENTATION OF NEW COMMISSIONERS
Scope
The Commission undertakes an orientation for new Commissioners and new staff. The orientation
is primarily undertaken by the Director with assistance from the Commissioners and/or from the
staff as needed. For new Commissioners, a portion of the orientation will be to “shadow” visits to
campuses and thus become better acquainted with the actual operation of a campus visit and become
acquainted with campus personnel.
Before leaving home
It would be helpful to the new Commissioner to receive information about important issues prior to
leaving home country. For example, the need to have all education documents (such as diplomas
and transcripts) attested by the department of state of the country of the institution and then
documented by the UAE Embassy. In addition, verification of dates and titles for professional
employment will be requested by the Ministry’s HR department as part of the hiring process. New
Commissioners would find it helpful to be informed of the requirement in UAE of having to pay
rent for one full year before moving into an apartment and the importance the obtaining an UAE ID
quickly. Concrete advice on the level of cash needed when arriving in UAE would be helpful.
First Day of Orientation:
Part of new Commissioner’s orientation will be to supply the individual with a complete document
collection including latest versions of Standards, Procedural Guidelines, QFEmirates, Annual
Report, Policy and Procedures Manual, Self-Study of the CAA and copies of forms required to be
completed by the Commissioner as part of his/her responsibilities. New Commissioners should be
supplied with desk supplies on first day.
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First Week of Orientation
New Commissioners will work with staff to ensure access to CORE, HR database and other IT
functions such as email addresses. Applications for tenant card, MoE identification card, Emirates
ID and other necessary documents will be given to new Commissioners along with help in arranging
physical exams and fingerprinting. New Commissioners should be given a tour of the IPIC building
and the surrounding areas and introduced to the store All Day and to the restaurant on site.
First Month of Orientation
New Commissioners will shadow Commissioner(s) as he/she begins the process of recruiting ERT,
facilitate travel arrangements, selects chair, compiles agenda, gives instruction to ERT and the
Institution and completes all necessary reports and forms. New Commissioners will also “shadow”
visits to campuses and thus become better acquainted with the actual operation of a campus visit
and become acquainted with campus personnel.
Purpose
To define the orientation program for new Commissioners.
WORKING HOURS/ HOLIDAYS
Scope
The normal working day of the Commission is 8:00am to 3:00pm. During Ramadan, hours are
shortened for staff to accommodate religious customs. Those not practicing the Muslim faith are
expected to adhere to normal working hours during Ramadan. The Commission honors the public
holidays declared by the Cabinet and which apply to all governmental employees. These holidays
are typically announced 10 days to two weeks in advance of the holiday. There will be times when,
at the discretion of the Director, flexible scheduling is needed to undertake the work of the
Commission. Such scheduling is not the norm and must be approved by the Director in advance.
As professionals and salaried employees, the Commissioners are expected to be available on some
occasions outside of the normal work hours.
Purpose
To guide Commissioners and staff with regard to Commission specific issues for the work day and
holidays.
POSITION DESCRIPTIONS
The following position descriptions can be found in Appendix 2
 Director CAA
 Commissioner
 Logistics Officer
 Research & Documentation Officer
29
 Archiving & Database Analyst
 Administrative Assistance Positions
Each position description contains the following information:
 Position Summary
 Educational Requirement
 Experience Required
 Language Requirements
 Required Skills
 Duties and Responsibilities
 Physical Requirements
 Supervisory Responsibilities
 Position Supervisor
30
ANNEXES
31
ANNEX 1 Initial Accreditation Process
32
ANNEX 2 Renewal of Accreditation Process
33
ANNEX 3 Initial Licensure Process
34
ANNEX 4 Renewal of Licensure Process
35
ANNEX 5 Substantive Change Process
36
ANNEX 6 CAA Strategic Plan 2020-2024
Mission
To work collaboratively with stakeholders to assure the quality, effectiveness and continuous
improvement of higher education, safeguard its system, embrace its diversity and foster the quality
culture.
Vision
To provide leadership by upholding quality assurance standards that promote distinction, innovation
and academic excellence within higher education.
Core Values: ACCREDITS

A: Accountability
We are accountable to the Ministry of Education and to the people of the UAE.
C: Collaboration
We work in a spirit of collaboration and partnership with Higher Education institutions.
C: Communication
We communicate clearly, accurately, and fully with partners and stakeholder and seek and
welcome their feedback
R: Responsiveness
We are responsive to the evolving needs of the higher education sector and its stakeholders
E: Excellence
We aim to achieve the highest standards in what we do and to encourage institutions to meet
their ambitions at the highest level
D: Diversity
We embrace diversity in the provision of higher education
I: Integrity
We adhere to established standards, policies and procedures and to established professional
ethics in all that we do.
T: Transparency
We are transparent in all our activities while respecting each institution’s confidentiality.
S: Sustainability
We are committed to sustainable practices.
Strategic Goals
1. Provide institutional licensure and program accreditation services using contemporary and
37
2. Foster capacity building activities and a creative work environment within the Commission to
3. Cultivate an organizational culture that is based on a robust internal quality assurance system and
4. Adopt collaborative practices with other accreditation and education agencies to improve
5. Advance the role of the Commission as a respected international leader of quality enhancement
in higher education.
Strategic Goals 1:
Provide institutional licensure and program accreditation services using contemporary and
Strategic Objectives Initiatives

a. Ensure that he CAA 1. Renewing INQAAHE accreditation
Standards are aligned with PI: Percentage progress in the renewal of INQAAHE accreditation
international best practice 2. Maintain WFME accreditation
PI: Annual status report is accepted by WFME
3. Conduct joint accreditation activities with international
agencies
PI: Percentage of conducted joint reviews per year from the total
number of each discipline’s reviews
b. Construct active feedback 1. Developing and deploying annual Stakeholders satisfaction
loops with stakeholders and surveys (Institutions and ERT)
collaborators. PI: Survey is developed and deployed per year
2. Organizing of regularly scheduled meetings with stakeholders
to exchange feedback.
PIs:
- Number of meeting per discipline per year
- Stakeholders’ feedback items collected per year
- Stakeholders’ feedback items adopted per year
- Stakeholders’ satisfaction survey results
c. Promote and assure quality 1. Providing auditing criteria to facilitate the adoption of distance
of learning in a variety of learning as a credible modality.
delivery modes within PI:
higher education including - Criteria is developed and communicated to institutions
distance learning to increase - Percentage of institutions achieving acceptable assessment
its effectiveness and its according to the criteria
ability to respond to 2. Support the development of a national survey of student
challenges. satisfaction, employability and final destination of graduates
38
PI: The survey is developed and deployed
Strategic Goals 2:
Foster capacity building activities and a creative work environment within the Commission to

a. Utilize a robust and 1. Developing and deploying an annual Professional
sustained Professional Development program that cater to the needs of the
Development program for commission’s work environment.
the Commissioners. PI:
- Stakeholder satisfaction survey results
- Parentage of Commission employees’ utilization of activities
2. Encouraging commissioners to participate in international
professional development events
PIs:
- Percentage of commissioners attending at least one
international event per year
- Percentage of expenditure on professional development from
the Commission’s budget
b. Recruit skilled 1. Developing a systemic recruitment and selection process that
administrative staff to supports CAA operational efficiency.
enhance operational PI:
efficiency - Number of staff recruited and hired
- Retention rate of staff
c. Adopt efficient information 1. Creating an integrated database and workflow system for
management systems that information management, document control, and process
improve the efficiency of facilitation.
the Commission. PI: Fully functioning automated system is that can generate essential
forms, obtain signatures, and permit distributive decision
making is developed and deployed
2. Developing an intuitively indexed archiving and document
management system.
PI: DMS is developed and deployed
3. Developing process for evaluating the functionality of the
information management systems
PI: Process is developed and deployed
39
Strategic Goals 3:
Cultivate an organizational culture that is based on a robust internal quality assurance system and

a. Develop and implement 1. Developing a system of the periodic evaluation of policies and
understandable and procedures for updates amd improvement or formulating
transparent policies and newly required ones.
proceedures. PI:
- Percentage of policies evaluated
- Percentage of policies substantially modified
b. Maximize the use of 1. Maintaining a primary set of processes and outcomes KPIs that
strategic planning and are reported annually, for example:
performance measurement. A. Average time required for an accreditation decision from
receiving the application to communicating the CoC
decision.
B. Percent of applications reviewed within 6 months of
submission
PI: Percent of annually achieved KPIs
c. Collaborate with federal and 1. Create joint strategy teams between federal and local agencies
local agencies that impact to provide continuous oversight
the quality of higher PI: Membership of teams and meetings per quarter.
education
Strategic Goals 4:
Adopt collaborative practices with other accreditation and education agencies to improve

a. Negotiate and approve 1. Conducting joint accreditation reviews when possible and
agreements with appropriate
accreditation bodies and PI:
other education agencies. - Percentage of conducted joint reviews per year based on the
total number of each discipline’s reviews
- Stakeholder evaluation of effectiveness of the joint visits
(Institutions, international bodies, Commissioners)
b. Seek mutual professional 1. Exploring the possibility of inter-agency professional
development opportunities development events (e.g. conferences and webinars)
and sharing of best PI: Number of professional development events undertaken
practices 2. Organizing workshops, seminars and webinar where best
practices are shared
PI:
40
- Number workshops, seminars and webinar organized per
year
Strategic Goals 5:
Advance the role of the Commission as a respected international leader of quality enhancement in
higher education.

a. Compile and maintain a 1. Developing an enhanced CAA webpage
comprehensive quality database of PI: Percentage progress in publishing the new website for
guides for quality improvement and the Commission
enhancement in higher education 2. Promoting the sharing of tools, dissemination of
guidelines and publications of best practices
PI: Number of best practices published annually
b. Contribute to the development of a 1. Providing professional development opportunities
culture of academic quality seminars and workshops to stakeholders
enhancement in the UAE and PI:
internationally. - Number of professional development opportunities
seminars and workshops offered to stakeholders
- Number of attendees
2. Collaborating with stakeholder to publish quality-
related research in international outlets.
PI:
- Number of collaborative quality-related publications
per year
- Number of all quality-related publications per year
c. Recognize exemplary practice by UAE 1. Defining and implementing criteria for a national
Higher Education Institutions through quality award for Higher Education Institution’s
national CAA Quality Award PI: Launch an annual National CAA Quality Award
41
ANNEX 7 Council of Commissioners (COC)
Authority
The authority of the Council of Commissioners (hereafter Council) is derived from the Minister of State for Higher
Education.
Membership
The membership of the Council is comprised of:
* The Director of the Commission for Academic Accreditation (hereafter CAA), as

Chair;
* The Deputy Director of Academic Affairs;
* All appointed CAA Commissioners.
A member of the administrative staff of the CAA, designated by the Director, serves as (non-voting) Secretary to the
Council.
Responsibilities
The Council has the authority to:
 discuss and approve all recommendations made by External Review Teams (ERTs) concerning Institutional
Licensure and Program Accreditation;
 discuss and approve all actions proposed as a result of Stage Two Investigations of concerns, Institutional or
Program Audit visits, or other special reviews;
 approve the imposition or removal of sanctions on an institution, or on one or more academic programs within
an institution;
 periodically review the Standards for Institutional Licensure and Program Accreditation, and make
recommendations for their revision or modification;
 periodically review other guidance documents issued by the CAA to institutions;
 determine assignments of licensure and accreditation reviews to Commissioners;
 advise the Director on matters relating to the effective functioning of the CAA;
 develop and adopt plans for workshops, seminars, and other activities that support the continued professional
development of institutions;
 consider and approve proposals for cooperation with other accreditation bodies;
 consider any other matters relating to the CAA’s activities, or referred to it by the Director.
Procedures
The Council will meet at least once each calendar month. The Director may at any time call for a special meeting of the
Council at any time, with a minimum of 24rs notice to all potential voting participants.
The Director normally presides over all Council meetings. The Director may appoint a designee with full discretionary
power to preside over a meeting in his absence.
42
The Director may invite CAA administrative staff or other individuals to attend a meeting of the Council as observers,
or to expedite discussion on a particular agenda item. Such individuals will not have voting rights.
The quorum for a meeting of the Council is >50% of all members.
The Secretary will distribute an agenda to all members at least one day before the meeting date. This agenda will
include Executive Summaries for all ERT reviews on which the Council must act.
Executive Summaries for ERT reviews normally will be introduced for discussion and approval by the Commissioner in
charge of the review. In his/her absence, a nominated Commissioner may introduce the Executive Summary.
Agenda items for action may be approved by unanimous consent. When a vote is taken on an agenda item, approval is
by simple majority. Each member of the Council has one vote. In the event of a tie, the Director or his designee will
have the casting vote.
Minutes of each meeting will be taken by the Secretary or designee, and circulated to all Council members.
43
APPENDICES
44
APPENDIX 1: CAA ORGANIZATIONAL CHART
59
APPENDIX 2: CAA POSITION DESCRIPTIONS
Director
Position Summary
The Commission is responsible for recommending institutions for institutional licensure and
accreditation of academic programs. The Director is responsible for all managerial and operational
matters required for the Commission to perform its duties and responsibilities, including the conduct
of reviews of institutions for initial licensure, licensure and re-licensure and the conduct of reviews
of academic programs for initial accreditation, accreditation and re-accreditation. The Director is
responsible for following-up on reviews and requirements for licensure and accreditation with
institutions.
Educational Requirements
An earned doctorate from an accredited institution in any academic area, with preference for
background in higher education policy or quality assurance, business, engineering or health
professions.
Experience
The Director must provide the following:
 Evidence of having earned the rank of Professor.

 Evidence of at least 5 years of academic administration at a senior level, dean or above.
 Evidence of a strong commitment to the quality assurance processes for building educational
excellence.
 Evidence of knowledge of accreditation systems through writings, and/or participation in
accreditation visits to institutions, either regional/national or professional bodies, as a team
member or chair or experience in a regional/national accrediting body.
Language
Proficiency in English and Arabic is required.
Required Skills
The Director must provide evidence of the following capabilities:
 An ability to work efficiently in a highly complex, sometimes ambiguous, constantly changing,

and demanding environment in which original thinking must be employed to arrive at solutions.
 Must be able to deal with simultaneously occurring crises which may compete for time.
 An ability to interact extensively with senior management to educate, influence, and build
awareness of key issues and propose solutions.
 An ability to influence and negotiate with external parties for the benefit of the CAA.
 An ability to engage others to work together towards a shared vision and common goals.
59
 Makes effective decisions.
 Achieves outcomes and results.
 High level computer skills, including word processing and database management.
 Ability to use good judgment in decision-making.
 Strong interpersonal and communication skills.
 Personal initiative and an ability to work independently.
 An ability to work as a team member.
 Organizational skills and an ability to follow up on necessary actions.
 Flexibility, an ability to adapt to change, and an ability to work under pressure.
 Maintenance of a high level of accuracy and attention to detail.
 Responsible and accountable for assigned duties.
 An ability to work in a diverse multicultural environment.
 An ability to analyze situations and to solve problems as they arise.
 An ability to work in a multi-cultural team environment and maintain strong working relations
with staff in CAA and with IT staff in the MoE.
 Collaborative and participatory philosophy in working with institutions.
 A proven ability to be firm but fair in applying the Standards for licensure and accreditation.
 An ability to be flexible, creative, responsible, patient and persistent.
 An ability to maintain confidentiality.
 Strong analytical and critical thinking skills.
 Excellent writing skills.
 Strong interpersonal skills.
 An ability to deal with people of diverse cultural backgrounds.
 An ability to prioritize, work under pressure and meet stated deadlines.
 Strong IT skills, including data base management skills.
 A commitment and ability to work in a collaborative team environment.
 Willingness to travel for extended periods of time within the U.A.E. to conduct the work of the
CAA.
Duties and Responsibilities
The Director is required to:
 Effectively manage all matters related to the operation of the Commission.

 Review all Commissioner and Visiting Committee analyses of institutional applications for
licensure against the Standards for Licensure and Accreditation.
 Review all Commissioner and Visiting Committee analyses of academic programs for
accreditation against the Standards for Licensure and Accreditation.
 Ensure that staff support is provided to visiting teams for licensure and accreditation visits.
 Review the Standards for Licensure and Accreditation for revision and updating.
 Work with consultants to develop new documents for licensure and accreditation in areas not yet
developed by the CAA.
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 Conduct meetings with institutional heads and other senior level staff on various issues related to
licensure and accreditation.
 Participate in activities to enhance the public knowledge of the value of licensure and accreditation
in the UAE.
 Mentor institutions for ensuring quality processes, procedures and policies for institutional
effectiveness.
 Ensure prompt and appropriate response to institutional requests.
 Follow-up on visits to institutions and reports emanating from visiting committees to make
recommendations for licensure or accreditation
Physical Requirements
The job is primarily sedentary in nature with no unusual physical capabilities required.
Supervisory Responsibility
Under the direction of the Minister for Education, the Director is expected to exercise supervisory
responsibilities related to office operations.
Supervisor
The Minister of Education.
Commissioner
Position Summary
The Commission is responsible for recommending institutions for institutional licensure and
accreditation of academic programs. Commissioners conduct reviews of institutions for initial
licensure, licensure and re-licensure and conduct reviews of academic programs for initial
accreditation, accreditation and renewal of accreditation. The Commissioners are responsible for
following-up on reviews and requirements for licensure and accreditation with institutions.
Educational Requirements
An earned doctorate from an accredited institution in any academic area, with preference for
background in higher education policy or quality assurance, business, engineering or health
professions.
Experience
A Commissioner must provide the following:
 Evidence of having earned the rank of Professor.

 Evidence of at least 5 years of academic administration at a senior level, dean or above.
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 Evidence of a strong commitment to the quality assurance processes for building educational
excellence.
 Evidence of knowledge of accreditation systems through writings, and/or participation in
accreditation visits to institutions, either regional/national or professional bodies, as a team
member or chair or experience in a regional/national accrediting body.
Language
English is required. Proficiency in English and Arabic is preferred.
Required Skills
A Commissioner must provide evidence of the following capabilities:
 An ability to work efficiently in a highly complex, sometimes ambiguous, constantly changing,

and demanding environment in which original thinking must be employed to arrive at solutions.
 An ability to interact extensively with senior management to educate, influence, and build
awareness of key issues and propose solutions.
 Personal initiative and an ability to work independently.
 An ability to work as a team member.
 Collaborative and participatory philosophy in working with institutions.
 A proven ability to be firm but fair in applying the Standards for licensure and accreditation.
 An ability to be flexible, creative, responsible, patient and persistent.
 An ability to maintain confidentiality.
 Strong analytical and critical thinking skills.
 Excellent writing skills.
 Strong interpersonal skills.
 An ability to deal with people of diverse cultural backgrounds.
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 An ability to prioritize, work under pressure and meet stated deadlines.
 Strong IT skills, including data base management skills.
 A commitment and ability to work in a collaborative team environment.
 Willingness to travel for extended periods of time within the U.A.E. to conduct the work of the
CAA.
A Commissioner is required to:
 Establish External Review Teams of professional experts, work with senior university
officials, and coordinate logistical details of institutional and program reviews.
 Supervise External Review Teams, representing the Commission a member of the Teams,
providing orientation and ensuring that they adhere to the CAA Standards and Procedural
Guidelines.
 Write detailed compliance reports and edit for legal sufficiency.
 Monitor institutional compliance with requirements set by the Commission.
 Consult with University Chancellors, Vice Chancellors, Presidents, and Senior Officers
regarding compliance issues.
 Monitor institutions for compliance with UAE regulations governing quality assurance and
institutional effectiveness.
 Review Applications for Initial Licensure and Program Accreditation for compliance with
CAA regulations.
 Mentor institutions for ensuring quality processes, procedures and policies for institutional
effectiveness, including making Special Institutional Visits for a range of purposes.
 Prepare, lead, and participate in Workshops and Seminars on special topics relevant to
quality enhancement.
 Participate in activities to enhance the public knowledge of the value of licensure and
accreditation in the UAE.
 Revise the existing Standards for Licensure and Accreditation as necessary.
 Draft regulations, policies and procedures in new areas, working with consultants as
necessary.
Under the direction of the CAA Executive Director and upon his or her designation, Commissioners
occasionally are expected to exercise supervisory responsibilities related to office operations.
Supervisor: Director, Commission for Academic Accreditation
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Logistics Officer
Position Description
The Logistics Officer supports office operations by ensuring that all logistical details, finances and
travel arrangements for the Director, Commissioners, CAA staff, and external review team members
will be executed in a timely and professional manner. The Logistics Officer will work closely with
the Director to ensure the operations of the CAA office related to logistics and financial details run
efficiently, smoothly and professionally.
Education Requirements
Postsecondary education or certification appropriate for the position..
Experience Required
5 years’ experience as an administrative assistant with responsibility for coordinating travel

arrangements and financial matters.
Language
Must be bi-lingual: Arabic and English
Required Skills:
The following skills and capabilities are required of the Administrative Officer/Travel Coordinator:
 An ability to work efficiently in a highly complex, sometimes ambiguous, constantly

changing, and demanding environment in which original thinking must be employed to
arrive at solutions.
 Personal initiative and an ability to work both independently and as a team member.
 Ability to work in a multi-cultural team environment and maintain strong working relations
The Logistics Officer shall:
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 Provide high level administrative support to the CAA.
 Provide flawless translation from English to Arabic and Arabic to English and liaison with
Arabic Speaking institutions.
 Coordinate travel arrangements with travel agency for visiting committee members
including:
o Flight requests & booking.
o Hotel stays.
o Car rentals.
o Taxis.
o Airport meet & greet

 Ensure that all travel arrangements are done in accordance with CAA policies and
procedures.
 Update and monitor changes in flights and arrangements with other travel service providers.
 Prepare cost estimation for site visits
 Preparation of money arrangements, correspondence, and required receipts for honorarium
and other expenses for the Committee Members
Supervisor
Director of the Commission.
Research and Documentation Officer
The Research and Documentation Officer (RDO) coordinates, implements and maintains the CAA’s
Document Control and established policies and procedures for the smooth functioning of the office.
He/she must have effective planning and organizational skills, with the ability to work with a high
degree of accuracy and recall. The RDO must have strong verbal and communication skills, good
computer skills and must be self-motivated to handle, organize and prioritize multiple tasks, be able
to perform under pressure to meet deadlines, and effectively participate on multi-disciplinary teams.
Master’s Degree from an accredited institution.
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Experience Required
Minimum 5 years’ experience working in an administrative role with senior management, preferably
in an educational institution.
Language
Must be bi-lingual in Arabic and English
Required Skills
The following skills and capabilities are required of the RDO:

changing, and demanding environment in which original thinking must be employed to
arrive at solutions.
 An ability to deal with simultaneously occurring crises which may compete for time.
 A demonstrated capability to use good judgment in making effective decisions.
 Proven experience in achieving outcomes and results.
 An ability to work in a multi-cultural team environment
The RDO is responsible for the following:
 Directs quality initiatives in work place by requiring adherence to quality assurance policies
and procedures; developing new models and implementing changes.
 Conducts research and drafts policy and procedures, as directed.
 Analyzes data from relational data bases and produces required reports.
 Provides technical and administrative support to update and maintain the CAA web-site.
 Coordinate, prepare, and submit Reports to the Minister’s Office when needed or requested.
 Documenting/Recording Information - Entering, transcribing, recording, storing, or
maintaining information in written or electronic form.
 Creates and maintains accurate and updated databases and spreadsheets to track CAA
activities.
 Maintains current knowledge of the Standards for Licensure and Accreditation.
 Provides organizational and technical support to institutional meetings and technical
committees.
 Prepares correspondence and reports, as requested.
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 Carries out assigned project work under the guidance of the Director.
 Provides general support to facilitate the work of the CAA, including but not limited to
maintaining accurate and complete files; preparing agendas and other documents as needed;
coordinating institutional responses to data requests; compiling reports, documents and
materials; replying to inquiries and requests.
 Generating comprehensive status reports detailing the various stages of an institution’s or
program’s progress toward licensure or accreditation.
 Ensuring the security of the institutional documents.
 Maintaining, in cooperation with the CAA database analyst, a permanent backup file of
electronic copies.
Supervisor
Director of the Commission
Archiving and Database Analyst
Position Summary
The Archiving and Database Analyst (ADA) will be responsible for performing data analysis,
structure, design modeling, documentation, training and maintenance of new and existing CAA
database applications. In addition, the ADA will be responsible for conducting research and preparing
statistical and other reports required by the CAA. The Database Analyst will administer and manage
relational database management systems used by various administrative applications. The Database
Analyst coordinates with the Administrative Facilitator and Finance Officer and reports to the
Executive Director
Bachelor’s degree from an accredited college or university in Computer Science, Management

Information Systems or related area.
Experience Required
 5 years’ experience as a programmer and database administrator.
 Experience in document imaging and scanning applications.
 Experience in research and report writing.
 Evidence of ability to conceptualize data needs and transform them to databases, and generate
reports based on the data.
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Supplemental Experience
 Experience working in an institution of higher education is a plus.
Language
Required Skills
The following skills and capabilities are required of the Database Analyst:

changing, and demanding environment in which original thinking must be employed to arrive
at solutions.
 Ability to work under pressure to produce high quality work according to designated
timeframes.

The Archiving and Database Analyst shall:
 Provide efficient and reliable administration and maintenance to the relational database
management systems to enable users to utilize the databases.
 Undertake relational database management system installation, database configuration and
support of new and existing systems to facilitate data sharing among users, environments and
applications.
 Analyze CAA systems and database applications, identity data and reporting needs of the CAA
and its licensed institutions, design and develop suitable applications.
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 Work with IT team at the MoE to ensure consistency with requirements and adherence to
development standards for web-based applications.
 Develop and implement database security policies/applications of the CAA.
 Develop and maintain distributed databases across integrated networks to facilitate user query
and reporting needs.
 Develop and document standards for use, control, updating and maintenance of databases.
 Provide ongoing consulting and troubleshooting support on all new and exiting systems.
 Provide technical and functional support for administrative applications as well as analyzing,
designing and developing new applications.
 Provide training to CAA Commissioners and staff.
 Participates in team project management for maintaining and developing system.
 Analyzes and recommends necessary hardware and software to meet CAA needs.
 Establishes and verifies database backup and disaster recovery plans. Fixes program bugs,
applying data fixes and providing user requested changes and enhancements.
 Write policies and procedures and documents all applications.
 Analyzes data and produces reports, as requested.
Specific Responsibilities
 Creating and supporting a master database of all data relating to all institutions in the UAE
 Providing comprehensive web-based and other reports and charts on institutional data
 Creating and maintaining a database-driven CAA website
 Creating systems to automate the various functions of the CAA.
None
Supervisor
Administrative Officer
The CAA Administrative Officer supports office operations by ensuring that correspondence and
other communications with external institutions, individuals, and government or non-governmental
entities are prepared in a professional form for transmittal. The Administrative Officer acts as the
first point of contact in responding to phone calls, e-mails, and incoming customer requests for
56
information and other assistance. The Administrative Officer ensures that incoming documents are
properly recorded and forwarded to the appropriate CAA staff for processing.
Appropriate degree/diploma/or certification of office skills, including, specifically, IT skills required

for daily administrative support tasks.
Experience Required
 5 years’ experience in an administrative support position.
 Experience working in a fast-paced, highly demanding, high performance environment.
 Extensive experience in using various forms of office software such as Microsoft Office
applications, including Word, Excel, etc.
Language
Required Skills
The following skills and capabilities are required of the Administrative Officer:

changing, and demanding environment in which original thinking must be employed to arrive
at solutions.
 High level professional capabilities in the application of various forms of IT office software
including Microsoft Office applications.
 Organizational skills, including the ability to multi-task and to prioritize assignments.
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The Administrative Officer shall –
 Perform all typing work (English/ Arabic) as requested by the CAA Executive Director.
 Arrange, organize and coordinate meetings and conferences for the Executive Director.
 Provide the Director with a daily report regarding the phone calls, visitors and all events
occurring during the day.
 Direct communication with institutions, individuals, and government or non-governmental
entities.
 Provide the initial response to incoming phone calls, e-mails, mail and faxes.
 Ensure that inquiries are forwarded to the appropriate Commissioner, Administrative officers
or to the Director if necessary.
 Initiate phone calls and e-mails as requested by the Director, Commissioners or Administrative
officers.
 Send faxes and letters on behalf of the Director, Commissioners or Administrative officers.
 Receive approved security clearances for new institutions or service providers and forward
them to the Undersecretary’s office for preparation of the decree.
 Update the institutional contacts on the website.
 Welcome visitors to Commission offices.
Supervisor
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APPENDIX 3: STRATEGIC ADVISORY COMMITTEE
Strategic Advisory Committee for the CAA
The Commission (CAA) Strategic Advisory Committee, comprised of accreditation, quality assurance,
and higher education experts, is established to review on regular basis CAA’s current practices on
licensure and accreditation and recommend best practices for CAA to utilize.
Functions of the Committee are:
1. To provide strategic advice on licensure, accreditation, and quality assurance issues related
to the goals and objectives of the CAA
2. To provide an independent evaluation at a strategic level of CAA activities including

accreditation, licensure, and validation of both programmatic and institutional currency and
viability.
3. To identify and advise on new developments, international accreditation initiatives, and

collaboration opportunities as appropriate to CAA mission.
4. To review current CAA procedures on accreditation and licensure and recommend best
practices for CAA.
5. To advise on and assist in developing strategy and procedures for sustaining and
strengthening oversight of CAA-accredited higher education institutions.
6. To provide advice on enhancing current CAA operations
Composition:
The Committee comprises of 7 accreditation, quality assurance, higher education, and technical
experts not affiliated with the CAA
Meeting:
The CAA Strategic Advisory Committee meets at least once a year and also communicates on a
regular basis through electronic communication means.
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APPENDIX 4: CRITERIA FOR TEACHING HOSPITALS
Introduction
It is acknowledged that the clinical experiential learning of health professional students may take
place in many types of clinical facilities such as local pharmacies, community clinics, private offices,
etc. This document addresses only hospitals/healthcare units (HCUs) and is not meant to apply in its
entirety to other types of clinical facilities that may be utilized in health professional education.
Teaching Hospitals/HCUs are a critical and important component to the preparation of healthcare
providers. Hospitals are focused on patient care whereas teaching hospitals/HCUs are focused on both
education and patient care. Hospitals/HCUs must meet certain criteria that assure that students
preparing to be healthcare providers will have adequate supervised learning experiences in the clinical
experiential learning of their program of study. This document outlines the general parameters for a
teaching hospital/HCU and the standards that must normally be met by a hospital/HCU (public or
private) to be considered as a suitable clinical learning site.
General
a. A teaching hospital for medical students must have at least four (4) qualified departments, two
(2) of which must be in the 'core' specialties of (i) medicine, (ii) obstetrics/gynecology, (iii)
pediatrics, (iv) surgery, (v) family medicine or (vi) psychiatry and have clinical resources
sufficient to ensure breadth and quality of ambulatory and bedside teaching of its medical
students and interns. On the other hand, a specialized hospital or HCU may have one qualified
department in the core specialties of medicine but is expected to maintain clinical resources
sufficient to ensure breadth and quality of ambulatory and bedside teaching of its medical
students and interns.
b. A teaching hospital for other healthcare providers must have departments that offer the breadth
of clinical experiences that is essential in the education of the student.
c. A teaching hospital should be in geographic proximity to the Higher Education Institution
(HEI) where the health professional program is housed to facilitate the integration of basic and
clinical science in the curriculum.
d. A teaching hospital will normally have adequate and sufficient facilities and staff to receive
health professional students from one or more HEIs. This will encourage and facilitate student-
to- student mentorship and collegial learning. The maximum number of students that the
hospital/HCU can receive will depend on the capacity of the facilities and dedicated faculty
assigned as instructors, mentors or preceptors. Clinical faculty are defined as hospital
healthcare professionals who are responsible for both patient care and student education.
e. A teaching hospital/HCU must have an organizational structure that supports health
professional education and patient care, and sufficient resources and commitment to
excellence meeting international standards in both. An ethical, professional and educational
environment in which curricular requirements, scholarly activity and general competencies
can be met must be demonstrated.
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f. A teaching hospital/HCU must demonstrate regular assessment of the quality of the clinical
experience, the performance of clinical faculty, and the use of outcome assessment results for
program improvement.
g. To be considered as a suitable clinical learning site, the hospital/HCU must demonstrate the
necessary educational, financial and human resources to support its educational mission.
Cooperative Agreement
A written, signed cooperative agreement between each respective HEI and the hospital/HCU must
exist and be made available to the MoHP and the MoE. At a minimum, it includes the following:
a. The educational programs for health professional students, including interns, remain under the
control of the HEI.
b. The evaluation of health professional students is shared between the HEI and clinical faculty,
while the evaluation of medical interns is kept under the control of clinical faculty.
c. The roles, responsibilities of each party related to the educational program must be defined.
d. There must be an orientation program for clinical faculty to become familiar with the
educational objectives of the health professional program including the clinical education
objectives and the internship, and how the adjunct clinical faculty will be prepared for their
roles in teaching and evaluation of health professional students.
e. The appointment/assignment of adjunct clinical faculty, their duties and responsibilities in the
clinical education program and in curriculum review for the health professional students must
be delineated.
f. There must be commitment to ensure that adjunct medical/clinical faculty have sufficient time
in their working schedule to facilitate the education of health professional students and interns.
g. The agreement must specify the evaluation process for an adjunct clinical faculty to continue
to be associated with the health professional education program, to include at a minimum, an
annual assessment conducted by both the hospital/HCU administrator assigned to oversee the
clinical education program and the responsible administrator at the HEI who oversees the
health professional education program. This should be informed by the students’ evaluations
of the adjunct faculty. A remediation plan for those with inadequate performance must be
included.
h. The financial obligations of each party to the training of health professional students and
interns must be delineated, including benefits and payments to adjunct clinical faculty, if
appropriate.
i. The responsibility for treatment and follow-up of health professional students and interns who
are exposed to infectious or environmental hazards and other occupational injuries must be
stated. This includes a mechanism to ensure the physical (including immunization status)
health of health professional students before entering the hospital.
j. The agreement must specify who is responsible for liability insurance for health professional
k. The rights and responsibilities of the students must be delineated, including policy for
addressing student grievances.
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l. The rights and responsibilities of adjunct clinical faculty in relationship to the HEI must be
delineated, for example, honorary appointments, library and database access, etc.
Additional Hospital/HCU Requirements
a. The hospital/HCU must maintain a Wide Area Network (WAN) for patient and MoHP
administrative purposes with adjunct clinical faculty, health professional students and interns
having access on a ‘need to know‘ basis. Policies must be in place to regulate the access of
adjunct clinical faculty, concerned staff, health professional students and interns to patients
and their records.
b. The hospital/HCU must develop and maintain a medical library, accessible to the health
professional students, interns and adjunct clinical faculty involved in the health professional
education programs at the hospital/HCU.
c. The hospital/HCU must respect the privacy of health professional students and interns and
adjunct clinical faculty.
d. The hospital/HCU must undertake to provide intern positions for all medical graduates of the
HEI to allow them to complete their training according to the regulations of the MoHP.
Administration of Teaching Hospitals/HCUs
a. There must be a designated officer who has authority and responsibility for the oversight and
administration of the hospital/HCU program, who works in conjunction with the designated
HEI officer in charge of health professional education. This individual must have appropriate
qualifications and experience, and responsibility for monitoring and advising on all aspects of
the clinical experiences at the hospital/HCU.
b. The hospital/HCU must have written policies and procedures in place for health professional
students and interns to guide their role, responsibility and authority while in the hospital/HCU.
These should include, but are not limited to the following: Duty hours that support the physical
and emotional well-being of the students, promotes an educational environment that facilitates
patient care; disciplinary regulations and grievance processes, substance abuse, sexual, and
other forms of harassment, etc.
c. The hospital/HCU must have in place a quality improvement process to assess the hospital‘s
performance and drive necessary improvement.
d. The hospital/HCU must have in place a Continuing Professional Education Program,
accredited by MOHP that is accessible to adjunct clinical faculty, health professional students
and interns as appropriate.
e. The hospital/HCU must demonstrate access to appropriate and confidential counseling and
medical and psychological support services for health professional students and interns.
Physical Facilities
A hospital/HCU that serves as a site for health professional students or interns must have appropriate
support space, instructional facilities and information resources.
It must provide documentation on the following:
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a. Sufficient areas for student study based on numbers of health professional students and interns.
b. Sufficient teaching space (classrooms) for the anticipated numbers of health professional
c. Sufficient lecture, large group discussion and conference facilities for health professional
students, interns and clinical faculty.
d. Sufficient and appropriate space within each department for small group meetings.
e. A well-maintained medical library of sufficient size and breadth and with sufficient
information resources to support the education program and other missions, including access
to leading biomedical, clinical and other relevant periodicals, either physical or electronic.
f. Sufficient numbers of computers equipped with appropriate education software and self-
instructional materials are designated for health professional students and interns that allow
access to the Internet.
g. Sufficient communication resources and IT support for the education program and other
missions.
h. Sufficient training equipment for the educational objectives of the health professional
education program to be met.
i. Sufficient numbers of on-call rooms for clinical students and interns.
j. Sufficient numbers of observation/examination/operatory rooms for health professional
k. Secure space e.g. lockers, for health professional students and interns to store personal
belongings.
l. Patient support services, such as pathology and radiology services, intravenous services,
phlebotomy services and laboratory services appropriate to and consistent with educational
objectives and patient care that support timely and quality patient care.
m. A medical records system that documents the course of each patient‘s diagnosed illness and
care that is available at all times and adequately supports quality patient care, quality assurance
activities and sufficient resources for scholarly activity.
n. Pagers and uniforms for the health professional students and interns if appropriate.
o. Available food service available to health professional students and interns.
Patient Data
The hospital/HCU must perform an analysis and summary of patient data that demonstrates that health
professional students and interns will get appropriate exposure and experience to patients.
a. The hospital/HCU must demonstrate a sufficient number of and types of patients in terms of
acuity, age, gender, and nationality for the hospital as a whole and for each department.
b. The hospital/HCU must provide data on admissions, both elective and emergency.
c. The hospital/HCU must provide data on the average number of admissions to each department
on a daily basis.
d. The hospital/HCU must provide the numbers of beds in the hospital and in each department.
This must be accompanied by patient occupancy data.
e. The hospital/HCU must provide data on the average number of outpatient and emergency
visits for the previous six (6) months.
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f. The hospital/HCU must provide data on the average number of surgical cases, both major and
minor, for the previous six (6) months, by type of surgery.
g. The hospital/HCU must provide data on the average number of lab and radiology requests for
the previous six (6) months.
h. The hospital/HCU must ensure security and confidentiality of patient records and that
appropriate and adequate provisions are made for back-up of all patient records.
Additional HEI Requirements
a) The HEI must provide expected outcomes for the clinical experiences of their students.
b) The HEI must provide and maintain specialized teaching equipment for the health professional
education program and intern program.
c) The HEI must provide and maintain an independent and physically separate IT network as part
of the institution’s WAN to provide access to its library and on-line resources and learning
materials.
d) The HEI must make available to the hospital/HCU its campus facilities for conferences and
exhibitions.
e) The HEI must cooperate with the clinical faculty to undertake joint research of common
interest, providing opportunities for students to also engage in the research process.
f) The HEI may appoint senior academics who will also be clinicians in relevant disciplines, who
also meet the MOHP requirements for appointment, to ’top up‘ designated health care
providers in the hospital/HCU to designate a department as meeting criteria for designation as
an approved department to fulfill the needs of health professional students and interns.
Adjunct medical/clinical faculty
The hospital/HCU must appoint and retain a broadly experienced and diverse adjunct medical/clinical
faculty who can serve as role models, are well trained and are enthusiastic about teaching.
a. Medical/Clinical faculty must meet the qualification and experience requirements for their
appointment set by the MoE (see Annex 20: Adjunct clinical faculty).
b. There must be at least one clinical specialist of senior rank and an appropriate number of
specialist health care providers with appropriate qualifications and experiences for a
department to be designated for clinical education.
c. A hospital/HCU must indicate the numbers of practicing healthcare providers, by specialty
that are qualified to be awarded clinical faculty status and their respective assignable ranks.
This must be confirmed by the HEI.
d. Criteria to be used to judge adjunct medical/clinical faculty should be based on the following:
i. Ability to teach, including having participated in a teaching program to understand new
methodologies for practice-based education, feedback and evaluation or commit
themselves to participate in a teaching methodology program organized by the HEI.
ii. An appropriate ongoing level of research/scholarly activity.
iii. Lifelong learning through CME/CPD programs.
iv. Minimum five (5) years clinical experience that evidences effective patient care
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APPENDIX 5: TEACH OUT
Institutional or Program Closure and Teach Out Plan
If an institution decides to close an educational program, branch campus, or the entire institution, it
must consider the following options:
a. The institution teaches out currently enrolled students; no longer admits students to programs;
and terminates the program, the operations of a branch campus, or the operations of an
institution after students have graduated.
b. The institution enters into a contract for another institution or organization to teach out the
educational programs or program. Such a teach-out agreement requires approval of the
Commission.
Teach-Out Agreements between Institutions
A teach-out agreement is defined as a written agreement between accredited institutions that provides
for the equitable treatment of students if one of those institutions stops offering an educational
program before all students enrolled in that program complete the program. If an institution enters
into a teach-out agreement with another institution, it must submit the agreement to the Commission.
For approval by the Commission, the agreement must be between institutions that are accredited by
the Commission and provide for the equitable treatment of students by ensuring that:
a. the teach-out institution has the necessary experience, resources, and support services to
provide an educational program that is of acceptable quality and reasonably similar in
content, structure, and scheduling to that provided by the closed institution; and
b. the teach-out institution demonstrates that it can provide students access to the program and
services without requiring them to move or travel substantial distances.
Closing a Program
When the decision is made to close an educational program, the institution must make a good faith
effort to assist affected students, faculty, administrative and support staff so that they experience a
minimal amount of disruption in the pursuit of their course of study or professional careers. In all
cases, individuals should be notified of the decision to close a program as soon as possible so that
they can make appropriate plans. Students who have not completed their programs should be advised
by faculty or professional counselors regarding suitable options including transfer to comparable
programs. Arrangements should be made to reassign faculty and staff or assist them in locating other
employment.
Closing a Branch Campus
A branch campus is defined as a location of an institution that is geographically apart and

independent of the main campus of the institution. A location is independent of the main campus if
the location is (1) permanent in nature, (2) offers courses in educational programs leading to a degree,
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certificate, or other recognized educational credential, (3) has its own faculty and administrative or
supervisory organization, and (4) has its own budgetary and hiring authority.
After the decision has been made to close a branch campus, all affected constituencies should be
notified promptly including students, faculty, administrative and support staff. The chief executive
officer should notify the Commission in writing as soon as possible. Every effort should be made to
assist current students to continue their education without disruption. Faculty and staff either should
be reassigned or assisted in locating other employment.
Closing an Institution
A decision to close requires specific plans providing in appropriate ways for the students, the faculty,
and the administrative and support staff, and the disposition of the institution's assets. Many
considerations bear upon closing an educational institution and each situation will be unique.
Nevertheless, general guidelines will be helpful to each institution considering closing.
A. The Students
Students who have not completed their degrees should be provided for according to their needs.
Arrangements for transfer to other institutions will require complete academic records and all other
related information gathered in dossiers that can be transmitted promptly to receiving institutions.
Agreements made with other institutions to receive transferring students and to accept their records
should be in writing. Where financial aid is concerned arrangements should be made to transfer the
grants to the receiving institution. Where such arrangements cannot be completed, students should
be informed. In cases where students have held institutional scholarships or grants, appropriate
agreements should be negotiated if there are available funds that can be legally used to support
students while completing degrees at other institutions.
B. Academic Records and Financial Aid Transcripts
Arrangements should be made with the Commission for filing of student records. Notification
should be sent to every current and past student indicating where the records are being stored and
what the accessibility to those records will be. Where possible, a copy of a student's record should
also be forwarded to the individual student. The institution must notify the Commission regarding
the final filing of student records.
C. Provision for Faculty and Staff
In every possible case, the institution should arrange for continuation of those faculty and staff who
will be necessary for the completion of the institution's work pending the closing date. In those cases
where faculty and staff will no longer be needed, the institution should make every effort to assist
them in finding other employment. It should be understood that the institution can make no
guarantees, but genuinely good faith efforts to assist in relocation and reassignment are essential.
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D. Final Determinations
Determinations must be made to allocate whatever financial resources and assets remain after the
institution provides for the basic needs of current students, faculty, and staff. When the financial
resources of the institution are inadequate to honor commitments, the board should investigate prior
to its decision to close what alternatives and protection are available under applicable UAE laws.
Every effort should be made to develop defensible policies for dividing the resources equitably
among those with claims against the institution. One of the best ways of achieving this goal is to
involve potential claimants in the process of developing the policies. Time and effort devoted to
carrying the process to a judicious conclusion may considerably reduce the likelihood of lawsuits or
other forms of confrontation.
It is impossible to anticipate the many claims that might be made against the remaining resources of
an institution, but institutions should give attention to the following three concerns:
a. Students have the right to expect basic minimal services during the final semester not only in
the academic division, but also in the business office, financial aid office, registrar's office,
counseling, and other essential support services. Staff should be retained long enough to
provide these services.
b. Staff should be willing to accept the possibility of early termination of their contracts,
provided that reasonable notice is given to all employees and that the reasons for retaining
some personnel longer than others are based on satisfying the minimal needs of students and
the legal requirements for closing.
c. Every effort should be made to honor long-term financial obligations (loans, debentures, etc.)
even though the parties holding such claims may choose not to press them.
E. The Closing Date
The final action of the board of trustees should be a formal vote to terminate the institution on a
specified date. Another key factor is whether or not all obligations to students will have been
satisfactorily discharged.
F. Disposition of Assets
In the case of a not-for-profit institution, the legal requirements of a state must be carefully examined
with respect to the disposition of institutional assets. Arrangements for the sale of the physical plant,
equipment, the library, special collections, art, or other essential holdings, and for the disposition of
any endowments or special funds must be explored. In the case of wills, endowments, or special
grants, the institution should discuss with the donors, grantors, executors of estates, and other
providers of special funds, arrangements to accommodate their wishes. UAE laws regarding the
disposition of funds from a non-profit institution must be meticulously followed.
G. Other Considerations
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An institution has the obligation to inform the Commission of its plans for closing and of its final
closing date. The institution should establish a clear understanding with its creditors and all other
agencies involved with its activities to assure that their claims and interests will be properly
processed. Insofar as possible, the institution should assure that its final arrangements will not be
subject to later legal proceedings which might jeopardize the records of its students or faculty.
Adapted from Middle States Commission on Higher Education, Southern Association of Colleges and
Schools, and Higher Learning Commission teach out policies. 12/09.
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APPENDIX 6: COMPLAINTS
Complaints Involving Institutions: Procedures
The following procedures will be followed for all complaints received by the Commission.
a. Complaints must be in writing and signed by the complainant. They should be submitted to
the Executive Director, who may assign the complaint to a staff member for substantive
review.
b. The complaint should identify the specific standards or fundamental elements, policies, or
procedures which have been allegedly violated. The Commission’s standards for accreditation,
Standards for Licensure and Accreditation, are available as a publication at the Commission
website http://www.caa.ac.ae.
c. The complainant should identify any steps already taken to resolve the complaint within the
process provided for by the institution.
d. The Commission recognizes the importance of timely resolution of complaints as promptly as

feasible, consistent with fairness to the complainant and the institution. It will acknowledge
receipt of all complaints within 30 days.
e. The Commission considers all complaints to be confidential between the complainant and the
Commission, until such time as written permission for disclosure is received from the
complainant or unless otherwise compelled by a court of law. The Commission will not contact
the institution concerning the complaint until such permission is received. However, the
Commission cannot proceed with its review unless the institution is permitted to see the
complaint and to respond to specific charges in the complaint.
f. If the complaint is not within the purview of the Commission, the Commission will notify the
complainant. If it is not clear whether the complaint appears to be within the purview of the
Commission, the complainant will be contacted for further information or documentation in
order to determine the status of the complaint.
g. If the complaint appears to be within the purview of the Commission, the assigned staff will
contact the complainant regarding the Commission’s consideration of the complaint, seeking
further clarification or support of the complaint in order to consider the complaint fairly, and/or
requesting authorization to forward the complaint to the institution for response.
h. After obtaining written permission from the complainant, the Commission will ordinarily
forward a copy of the complaint to the principal administrative officer of the institution and
request an institutional response. The institution is asked to respond to the Commission
regarding the complaint within 60 days after the Commission mails a copy of the complaint
and related materials to the institution. In consideration of the circumstances of, or issues
raised in the complaint, the Commission may, on occasion, request a response within a shorter
period.
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i. If an institutional response is not received by the Commission within the requested time period,
or if the Commission does not consider the institutional response to have satisfactorily
resolved the issue or issues raised in the complaint, or if the Commission otherwise concludes
that a violation of the Commission’s standards, eligibility requirements or procedures may
have occurred, the Commission may initiate further proceedings as the circumstances warrant,
including the initiation of proceedings which may result in an adverse accreditation action.
j. If a complaint prompts action by the Commission, it is placed in the institution’s file in the
Commission office and is shared with the next evaluation team. All complaint records are
maintained in the Commission office.
k. If the Commission determines that the institutional response satisfactorily addresses the
issue(s) raised in the complaint, or if the Commission is otherwise satisfied upon its own
review that no violation of the Commission’s accreditation standards or its eligibility
requirements has occurred, or that no violation of the Commission’s or institution’s policies
or procedures has occurred, the matter will be considered closed.
l. The Commission will attempt to notify the complainant of the results of the review in writing
within 30 days after the institution has submitted its response.
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APPENDIX 7: CHANGE OF OWNERSHIP OR CONTROL OF AN INSTITUTION
Policy
It is the policy of the Commission that requests for Substantive Change must be submitted at least
three months in advance of the proposed change in ownership.
The institution must provide documentation of the following:
a. Security clearance for the new ownership.

b. Membership roster of the Board of Trustees.
In addition, the institution submitting the request must include in his Substantive Change document,
answers to the following:
a. What is the current mission and vision of the institution and how will it change under the new
ownership?
b. Outline the current academic programs of the institution and explain how these programs will
be continued and supported subsequent to the change in ownership?
c. Explain the current mode of delivery (i.e. face-to-face, on-line, etc.). What plans are there to
change the mode of delivery?
d. Provide the business plan for the next five years after the change in ownership.
e. Provide an analysis of the impact of the change in ownership on principal support services for
the institution including technology and the library and facilities. Include in this analysis
assurances that the complete records of student performance (including transcripts) will
become the property of the new ownership.
f. If the change in ownership or control involves a change in location and a significant change
in the facilities available to the institution, the application must provide a rationale for the
change and evidence that the new and/or altered facilities will be able to accommodate the
programs and services of the institution.
g. Provide a financial analysis for the next five years after the change in ownership including
anticipated revenues and expenditures? Provide a financial guarantee of at least one year
should the institution stop admitting students.
h. Provide audited financial statements for the last two years prior to the application for
Substantive Change.
i. Provide a description of the current governance/management structure of the institution and
any anticipated changes that will occur under new ownership.
j. Provide an assurances from the new owner that they will maintain licensure through the
Commission and will maintain the accreditation of existing programs. It is a condition of
licensure that the institution seek accreditation for all new programs to be offered before they
begin admitting students to those programs.
k. If the change of ownership will result in the closure of any program, the application must
include a detailed “teach out” plan for students currently enrolled in the program.
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Procedures
a. Within 30 days after receipt of an application for Substantive Change involving a change of
ownership or control, the Commission will assign a lead Commissioner who will review the
application to ensure that all queries are answered and that the application is inclusive of
appropriate documentation.
b. After consultation with the director of the CAA, the lead Commissioner will invite an external
reviewer to review the application for Substantive Change; the lead Commissioner will also
undertake an independent review of the application.
c. The Commission may conduct a site review of the institution and may schedule an interview
with the prospective new owners to ascertain the commitment of the owners to maintaining
the quality standards set by the Commission.
d. Within 60 days after the lead Commissioner is named and after the review of the application
and supporting documents and after the site visit and associated interviews, the review team
(the external reviewer and the lead Commissioner) will draft a report for the director with an
accompanying recommendation regarding the proposed change. The recommendation may
take one of several forms:
i. Recommended approval of the change of ownership/control with the maintenance of
licensure and the accreditation of currently accredited programs.
ii. Recommend approval of the change of ownership/control only after the new
ownership submits an application for re-licensure under the new ownership.
iii. Recommend approval of the change of ownership/control but with required follow-up
reports on selected areas of the institution (i.e., governance, systems of quality
assurance or finance).
iv. Recommend denial of the change of ownership/control.
e. The director will consider the proposed change and, assuming that he/she endorses the change,
he will forward it to the Minister of Higher Education for final action within 30 days of the
receipt of the report from the lead Commissioner and the external reviewer.
f. The Minister of Education may accept the recommendation, defer the recommendation or
deny the recommendation. The decision of the Minister of Education is final.
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APPENDIX 8: RECEIPT OF APPLICATIONS
Receipt of Applications
Applications are received and will be accepted by the Commission at any time. The Standards and
the Procedural Guidelines include due dates of November 1 for those applications which an institution
seeks to have reviewed in the spring semester of the following year and May 1 for those applications
which an institution seeks to have reviewed in the fall semester of the year in which the application is
received.
The first priority upon receipt of documents from an institution is to determine whether or not all of
the required documents are submitted. The Director or his designee will distribute the applications to
the Commissioners who then receive an email from the office with an electronic link to the
application. The Commissioner downloads the application and reviews it for completeness.
The office is responsible for ensuring that all documents are date stamped upon intake and assigned
to a Commissioner for intake document assessment. Commissioners are assigned as lead
Commissioners on an application by the Director or his designate; generally this responsibility is on
a rotating basis.
At the discretion of the Director, incomplete submissions will be returned to the institution with a
notification listing missing documents and a citation from the Standards noting the requirements for
document submission.
To enable efficient storing, tracking and retention of documents for future reference
documents submitted to the CAA are separated into seven categories under three general
headings as follows: Accreditation: Initial Accreditation (IA) Renewal of Accreditation
(RA), Accreditation, (A); Licensure: Initial Licensure (IL), Renewal of Licensure (RI) and
Licensure (L), Substantive Change (SC) and Responses (R).
Institutions are required to submit one hard copy and three soft copies (USB drives) of new
submissions. For responses, one hard copy and three sets of soft copies are required. The
Commissioner begins to gather individuals that may be appropriate for the ERT. Members of the
ERT are selected on the basis of prior experience with the CAA, experience with broader accreditation
issues, expertise in the field under review, understanding of the institutional mission, and international
experience. Visiting ERT members that have demonstrated good performance on earlier CAA reviews
are retained in the "Registry of Reviewers," on CORE and, as appropriate, invited again to get the
benefit of their experience in the UAE higher education sphere and in working with the Standards.
When practicable, newly formed teams are constituted with a mixture of experienced and new
reviewers.
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APPENDIX 9: DETAILS OF ERT SELECTION, SITE VISIT ACTIVITIES,
COMMISSIONERS AND REPORTS
The objective is to secure a strong team from respected institutions with relevant, up-to-date discipline
and program experience, and appropriate gravitas. With widespread US-model education systems in
the UAE, priority is given to inclusion of ERT members from US institutions. Reviewers from
Canada, the UK, Australia, and other areas with English medium Higher Education Institutions are
also used. In searching for new ERT members consideration should be given to:
 Rank (Usually Professor, Dean or Associate Dean, Senior Lecturer – UK).

 Discipline experience as a Program Chair or other significant involvement in an allied
program.
 Accreditation/Validation experience.
 International experience.
Commissioners are expected to request a curriculum vitae/ Bio from potential ERT members at an
early stage. The potential ERT membership should be checked with the Director before confirming
their participation.
In considering the precise dates for the visit consideration should be given to:
 Number of days required depends on the type of review visit and the complexity of the
program.
 Potential ‘back-to-back’ visits to be arranged in the same visit period to get best value from
visiting teams.
 Public holidays.
 University calendar (e.g., avoid exam periods)
 ‘Blackout Dates’ on hotels due to high demand.
Visits normally commence on the Sunday or Monday with members of the ERT arriving in the UAE
the previous evening. Weekends (i.e. Fridays and Saturdays) may be used for visits to the institutions
where necessary (e.g. where visits run back-to-back). This may constrain the itinerary and
Commissioners must be sensitive to the religious requirements of the personnel of the institution.
Careful planning is needed along with agreement from the institution. The Commissioner will select
a potential Chair for the Committee and normally contact the member in advance of the visit to explain
the additional responsibilities and remuneration.
Invitation letters/e-mails to reviewers from the Commission indicate the nature of the work of the
Commission, the type of review (level and discipline field), likely dates for the visit, and the terms
and conditions (honorarium, per diem and the standard of accommodation and travel class). The
Commission’s web site is referenced in the letter so that potential reviewers can access the Standards
and learn more of the work of the CAA. The ERT’s monetary compensation is transferred directly to
the reviewer’s personal bank account in his/her home country. The initial invitation requests that an
individual submit his/her passport as a scanned pdf copy of the identification page. The passport page
is required for travel arrangements. The individual is also asked to fill out a visit form requesting basic
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information of home and work address, phone numbers, email address and other items as necessary.
The form is divided in three sections. The second section asks for the bank information, and
the third about travel preferences.
Commission staff can initiate travel arrangements and forwards the information to the travel
agent. The ERT member will be asked to confirm the flight arrangements before they are
finalized. The travel agent will email the travel routes and times and needs a response usually
within 48 hours since the reservation cannot be held any longer.
Following a positive response to the letter of invitation, the assigned Commissioner will forward to
the proposed ERT member:
 The Handbook for External Review Teams Members includes detail on the preparation,
logistics, reporting and expectations of the review.
 Declaration form regarding conflict of interest, confidentiality and other ethical
responsibilities of the reviews.
 A covering letter/e-mail providing more detail on the institution and specific program/s under
review.
 It is helpful for the ERT if the Commissioner includes an electronic copy of the Standards,
Procedural Guidelines for the specific review, and the Qualifications Framework Extracts
2013 (QFEmirates).
Following receipt at the CAA of the signed declaration form, the Commissioner will arrange for the
program documentation submitted by the institution to be accessible through a password-protected
electronic link. If requested by the ERT member, a hard copy of the program documentation will be
sent by a delivery service such as Aramex or FedEx.
The Commissioner will make up draft itinerary/schedule for the campus review visit. The
Commissioner usually shares the schedule with the ERT Chairperson for comments and suggestions
of any changes. The draft schedule should also be shared with the institution at an early stage to
ensure that key personnel will be available at the designated times. It is also helpful to ask the
institution to supply specific room numbers and the names of the individuals who will be interviewed
during the course of the ERT visit. The Commissioner will also inform the Institution about the
Commission’s request for the Base room which is the ERT’s conference room, and for transportation
needs. The following, if appropriate, will be forwarded to the Chairperson and the ERT.
 Samples of reports to guide the ERT members on the reporting style and level of detail
required in CAA reports should be shared with the ERT. It is often helpful to provide the ERT
with the most recent review report(s) for the specific campus. Such reports are available on
the CORE and give ERT members both a sense of what a report looks like and a sense of the
campus as well as conclusions from a prior external review team.
 Further explanation of the focus of the review and the proposed reporting responsibilities and
suggested allocation of the work in relation to Sections and Sub-Sections of the CAA
Standards.
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 A template which helps the reviewers in the writing of the report.
This may be combined with suggestions how to allocate responsibility for drafting particular sections
of the report. An experienced chairperson may suggest the distribution of the work particularly if
he/she is familiar with the fellow ERT members.
At the discretion of the Commissioner and the ERT, a Preparation Day in the UAE at the start of the
visit may be included in the agenda. This day is used to provide an orientation to the UAE in general
and its culture, Higher Education in the region, report formatting, conduct of meetings, and for fine-
tuning of the itinerary. It also is an opportunity to share observations on the program and to formulate
the areas for questioning and seeking evidence. The meeting is held either on campus or in the hotel
and it also serves to allow for some level of adjustment to the change in time zones and climate,
particularly for those arriving late the previous evening from the US. An alternative to the Preparation
Day is to schedule meetings on the first and second days and reserve the third day of the visit for
report writing. The lead Commissioner will develop the agenda according to the preferences of the
Commissioner and the ERT.
The Site Visit: Procedures
The Commissioner, working with the CAA office and the travel agent, confirms with ERT members
their travel itinerary, and arrangements for transport from the airport to the named hotel. The
Commissioner provides the ERT members with his or her cell phone number for emergency contact
and reminds them to bring laptops and 'flash drives/memory sticks'. On the day prior to the visit, the
Commissioner ensures that he/ she has a full set of the Application documents, a copy of the Standards
and laptop.
Prior to the Orientation meeting on preparation day, Commissioners should give instruction as to
when and where this first meeting will be. An email or a text message can be used for late greetings
and information. A hotel meeting room may be the best venue for Orientation unless the
Commissioner has a suite with separate meeting area. Alternatively, a meeting room at the institution
may be used for the Preparation Day, with no meetings with institutional officials scheduled.
Transport from hotel to Institution and back is handled by the Institution. The commissioner will get
the driver’s name and mobile number no later than a day before the site visit starts.
The itinerary is followed with a prompt start and finish to all meetings. The first meetings are critical
and investigation of issues should start as early as possible. Commissioners may need to adopt a
'hands-on' approach with the questioning, to get to key issues quickly. Any supplementary
documentation or meetings required by the ERT are considered early and notice given to the
institution (e.g., list of faculty to be interviewed by ERT). ERT members are prepared for meetings
with identified issues to address and information/ evidence to be acquired or confirmed. Any changes
to the agreed schedule are organized through the Commissioner and not by individual ERT members.
A record is kept of all those attending the meetings and that only those required at the meeting by the
ERT are present.
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It is often more informative if the ERT selects those faculty to be interviewed on a one-to-one basis,
and any student groups are pre-selected by the ERT.
A record (notes) are kept on the evidence base for informing the ERT on various issues.
Issues reviewed by the ERT are constrained to those areas of relevance to the Standards and the
specific exercise of accreditation. ERT is provided with suitable refreshments throughout the day and
the lunch arrangements are satisfactory. Transport is arranged for a prompt pick up at the end of the
day.
An evening dinner may be used to discuss findings and consider key issues to be addressed in the
remainder of the visit; some ERT members prefer to have their evenings free to engage in further
report writing. A quick executive session at the hotel is sometimes preferable to a more structured
evening dinner arrangement. Campuses are discouraged from providing evening activities for the ERT
or the Commissioner. The pressures of completing the report are too great to allow for such activities.
Drafting of report sections is started early in the visit, coverage is comprehensive and detailed, and
the final report (subject to CAA editing) is produced by the final day.
Prior to departure, the ERT has considered the key themes to cover in the exit meeting/s.
Before leaving, the team’s transport arrangements to the airport are confirmed and all members are
clear on times of check-out, transport to the airport, and flight bookings. Check with hotel concierge
if necessary.
The offer or request of a separate Exit Meeting with the CEO/Chancellor should be made to discuss
any sensitive institutional matters. This is separate from a standard Exit Meeting with the University
and College higher administrators and any invited person(s). A special meeting is usually held with
the University’s representatives, the Commissioner and the Chair only.
The ERT members are requested to complete CAA feedback forms on the visit. The Commissioner
will bring back the forms to the office.
The Report: Commissioner Responsibilities
In developing the final report, the Commissioner must remain cognizant of the fact that the report will
serve two principal audiences: the institution and the Commission. The report must be clear with
regard to what institutions must do in response to requirements rendered by the ERT. For each
requirement or suggestions, there must be clear narrative which tells an institution how the ERT
arrived at its conclusion. It must also be very clear to the institution as to what they must do in
response to requirements. Thus, there should be information on what is needed for the institution to
meet the requirement.
The Commission is using the following language to communicate its finding and decisions. The word
Recommendation should not be used. Instead we use the word Requirement.
Requirement X: ABC is required to (always begin with the institution).
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Suggestion X: The ERT suggests that ABC ….
It should also be remembered that another Commissioner may have to deal with responses in the
future. That Commissioner will need benefit of background and context so as to be able to decipher
the strengths, limitations, deficiencies and requirements with ease and clarity.
In order to finalize the report and allow all ERT members to review the report together, some
Commissioners find it helpful having a projector available at the institution or at the hotel to review
the report text on a larger screen and to discuss and finalize Requirements and Suggestions. Others
find that having print copies of the report available on the morning of the last day is the best way to
facilitate the final discussion during which time the ERT must achieve consensus on the requirements
and conclusions of the report. Most institutions can provide for facilities to display the report and/or
have sufficient printing capacity to help with this stage of the report writing/review process. The
Commissioner should request that the Base Room is equipped with a printer and has an LCD projector
and a screen available. This usually done as a Note to the University attached to the schedule.
Because of the confidential nature of the reports and the working documents, the members of the ERT
are urged to "claim" all working materials prior to the end of visit. Typically, ERT members do not
want to take such materials home with them. The Commissioner thus gathers the documents. The
Commissioner ensures that documents left by ERT members at the end of the visit are taken back to
the Commission to be disposed of appropriately.
The Commissioner also turns in required forms from the visit (Recommendation form from the ERT,
summary details on the visit form, evaluations of the visit done by the ERT members, evaluation of
the quality assurance unit). The Commissioner completes an evaluation regarding the performance
of ERT members directly in the CORE. This is to give guidance to other Commissions in recruiting
future ERTs.
Any initial editing of the ERT's report should be completed by the Commissioner within three weeks
of finishing the visit. The draft report should be circulated to the other Commissioners for their
scrutiny and comment. Comments are to be returned within a week. The Commissioner should make
every effort to complete the report within 30 days from the review visit. When the report has been
completed, the Commissioner will send the report with a cover letter to the highest administrator at
the University and with appropriate copies to other members of the University administration.
Institutions are given time to respond to a report, normally 60 days.
Responses and Final Action
The Universities normally have 60 days to respond to the Requirements and Suggestions. The
response to a requirement must be complete and with supporting documentation. Suggestions must
be responded to but do not necessarily have to be accepted.
The written response to the Report is recorded by the office staff and forwarded to the Commissioner
to evaluate the compliance with requirements made in the report. When the response includes
specialist curriculum and/or learning resource issues, it is likely that the ERT Chair will be required
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to comment on the level of satisfaction with the response and any further action required by the
institution. The response is sent to the ERT Chair usually by email, who will review and assess the
responses for completeness and accuracy. The Chairperson enters a narrative to clarify a decision. If
the response is not satisfactory, the Chair will include a note specifying what additional material the
institution needs to submit for the Requirement to be cleared. This entry is usually written below the
Institution’s response in the report. The Chair is also informed about the deadline.
The Commissioner will use comments from the ERT Chair, and his/her own evaluation of satisfaction
with institutional issues, to compile a written evaluation of the response. This may be a request to the
institution for further work on specified Requirements. The Commissioner ensures that the office
staff receives a copy to be maintained with the institution's file.
When all issues are dealt with in accordance with the Standards the Commissioner will finalize an
Executive Summary and present the report at the Council of Commissioner’s meetings. The Council
members will decide on a decision based on the report, the brief presentation and the response from
the Commissioner to any questions the members may ask. Finally, the Council members render a
decision on the disposition of the application.
The Director will write and sign a recommendation to the Minster of Education who makes the final
decision. Once approved by the Minister, a decree is issued, the institution is informed, and the name
of the institution and/or program will be added to the Commissions list of licensed institutions and
accredited programs which is available on the CAA website
Forms associated with the processes of reviews
Throughout the processes described above, several forms help in documenting each step, ensuring
all required information is gathered, financial responsibilities to ERT are met and summary data is
available for entry into CORE. These forms are listed below:
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APPENDIX 10: CAA FORMS
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Form 01
INSTITUTIONAL RISK EVALUATION

Institution
Type of Licensure
Dates of the Visit
Note: The determination of risk is undertaken by the External Review Team (ERT) at the conclusion of the
Institutional Licensure Review, and is based on two equally weighted elements:
Part A of the Risk Evaluation considers the extent to which the HEI (during the Institutional
Licensure review) has provided evidence of meeting the requirements of the Standards
Institution-Level Criteria
The institution has provided evidence of the extent to which it Fully Partially Limited/
has achieved the following: (score 2) (score 1) None
(score 0)
1 The institution has a vision statement that articulates the long-
term aspirations of the institution.
2 The institution has a mission statement that is periodically re-
evaluated to assess its currency.
3 The organization of the institution reflects and supports its
mission, and facilitates its efficient operation.
4 The governing body is subject to and operates under By-Laws.
5 The governing body regularly evaluates its own effectiveness.
6 Faculty members have sufficient opportunity to participate in
decision making on matters related to the curriculum,
assessment, and academic integrity.
7 Students have the opportunity to participate in the decision-
making processes within the institution.
8 All administrators and academic officers, including the chief
executive officer, are annually evaluated and are provided
feedback on those evaluations.
9 A Policies and Procedures Manual is available that contains all
the policies and procedures of the institution.
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10 The institution demonstrates its commitment to continuous
quality assurance and enhancement by systematically
evaluating the effectiveness of all aspects of its operations and
academic programs.
11 The institution demonstrates how evidence-based planning has
led to improvements in programs and services, to new programs
and services, and to more effective use of resources.
12 The academic programs and courses offered by the institution
are appropriate to its mission.
13 International academic norms are reflected in program design
and composition, in the delivery of teaching and instruction, and
in the assessment of student achievement.
14 The institution thoroughly assesses the need for any new
program, determining the potential employment market,
competition in the sector, prospective student interest, resource
requirements, and financial implications.
15 The institution has effective policies and processes for
advertising, recruiting, and appointing faculty and professional
staff members and maintains records of these processes.
16 The qualifications and experience of all professional staff
members are appropriate to the level of their appointment and
the duties to which they are assigned.
17 The institution employs a sufficient number of faculty members
to effectively deliver the programs it offers, both credit and non-
credit, in line with its mission and international norms.
18 The institution conducts annual evaluations of the performance
of all full-time, part-time, and visiting faculty members, and
professional staff members at all locations, using a variety of
measures.
19 The institution provides an environment that contributes to the
cultural, social, moral, intellectual, and physical development
of students.
20 The institution provides learning resources and services for
students and faculty members that adequately support teaching
and learning and, as applicable, research, in ways that are
consistent with the institution’s mission and goals.
21 The physical facilities are designed and maintained to serve the
needs of the institution in relation to its mission, and include a
sufficient number of classrooms and other specialized physical
resources to supports its academic programs.
22 The institution demonstrates present and future financial
stability, with resources adequate to accomplish its mission
effectively and to ensure that all enrolled students are able to
complete their academic programs.
23 The institution adheres to the highest ethical standards in its
teaching, research, scholarship, and service; in its treatment of
its students, faculty, and staff; and in its external interactions
and relationships.
82
24 In keeping with its mission, the institution supports research and
scholarly activities directed towards the creation, integration,
and application of knowledge.
25 The institution accepts its responsibility to serve the needs of
the local community in a variety of different ways, according to
the characteristics of the institution
Total points for Part A (out of 50) ( )
Part B of the Risk Evaluation evaluates the risk of strategic, operational, legal and financial, academic and
international dimensions as applied to specific risk statements, which take into account the risk analysis area.
The ERT will utilize its professional judgement in following this structured approach to evaluate the extent to
which risk is determined.
The five dimensions are scored on a confidence level assessment of factors which alleviate risk, ranging
between 1 (least confidence) and 5 (greatest confidence).
Risk Dimension Risk Statement* Confidence

Level Score
(1-5)
1. Strategic The risk that an event or action may adversely affect an institution’s
ability to achieve its strategic objectives as a licensed HEI in the
UAE.
2.Operational The risk that inadequate or failed internal processes, people and/or
systems, or external events may adversely affect an institution’s
ability to achieve its operational objectives as a licensed HEI in the
UAE.
3. Legal and Any risk that will affect the legal status or financial stability of a
Financial HEI and its ability to continue as a licensed HEI in the UAE.
4. Academic The risk of failing to achieve academic objectives and the
maintenance of academic quality and standards, specifically
relating to learning, teaching and research, that will adversely affect
the institution’s ability to achieve its strategic objectives as a
licensed HEI in the UAE.
5. International The risk of not achieving equitable National Classification,
international ranking, or international accreditation as compared to
peer institutions within the UAE.
Total points for Part B (out of 25) ( )
Adjusted Total Score for Part B (out of 50) ( )
* See the Supplementary Guidance to the Standards 2019 (pp. 16-18) for the risk evaluation criterion.
Total Score for Part A + Total Score for Part B (out of 100) = ( ) HEI Score
83
Risk Level Recommendation
We the undersigned members of the External Review Team recommend the following:
a. Low Risk: The institution provides high confidence in its ability to continually meet the
requirements of the Standards for Institutional Licensure and Program Accreditation 2019.
Total Score: 85-100 Frequency of Review: Licensure and program accreditation up to 7 years
b. Medium Risk: The institution provides confidence in its ability to continually meet the
Total Score: 70-84 Frequency of Review: Licensure and program accreditation up to 5 years
c. High Risk: The institution provides limited confidence in its ability to continually meet the
Total Score: < 70 Frequency of Review: Licensure and program accreditation up to 3 years
Name Signature Date
1.
……………………………………………… …………………………… ……………………

2.
……………………………………………… …………………………… ……………………

3.
………………………………………………… …………………………… ……………………

4.
………………………………………………… …………………………… ……………………

5.
……………………………………………… …………………………… ……………………
84
Form 02
QUALITY ASSURANCE SYSTEM- EVALUATION METRIC
Institution
Program
Commissioner
Dates of the Visit
Note to Commissioners: The program section of this form is completed at every program accreditation visit with respect
to that program / area. The institution section of this form should be completed at the first visit to an institution in a year.
If serious deficiencies are detected, this should be recorded in the CAA’s ‘notes on the institution’. In this case, the form
may be addressed again at a subsequent visit. Before visiting an institution, the Commissioner should check the schedule
to see if this institution has been visited earlier in the year and, if so, consult the notes on this institution to see if repeated
attention to this form is required.
INSTITUTION-LEVEL CRITERIA: Does the Institution have evidence of the following?
Q 1. A Quality Assurance Office YES NO
A full- time qualified and/or experienced Quality Assurance

Q 2.
Officer YES NO
Q 3. The Quality Assurance Officer reports directly to the CEO YES NO
Q 4. Adequate staffing of the QA Office YES NO
Q 5. A Quality Assurance / Institutional Effectiveness Manual YES NO
The Manual is good (e.g. complete, clear, covers all

Q 6.
institutional activities) YES NO
85
Q 7. A Fact Book YES NO
Q 8. An Annual Report YES NO
Q 9. Systematic institution-wide data collection and recording YES NO
Q10. Data analyses that inform planning processes YES NO
Systematic monitoring of the implementation of planned

Q 11.
improvements YES NO
In summary, are the QA Office and the institutional QA

Q 12. system functional to an acceptable level, having regard to the YES NO
stage of development of the institution?
86
Please add any comments on the efficiency and effectiveness of the QA Office and/or the QA system, including the apparent
institution-wide scope.
87
PROGRAM-LEVEL CRITERIA: Does the Program or Unit (e.g. Department / College) have
evidence of the following?
A system that involves all stakeholders, including external
Q 1. bodies, in the quality assurance processes YES NO
Evaluation processes and instruments that are used to inform

Q 2.
program reviews YES NO
A variety of ways of assessing and measuring student

Q 3.
performance YES NO
Q 4. A variety of ways of assessing faculty performance YES NO
Regular assessment of the performance of administrative and

Q 5. support staff YES NO
Q 6. Data gathered is analyzed and interpreted YES NO
Q 7. Data gathered is used for the improvement of the program YES NO
(for Renewal of Program Accreditation only)

Q 8. In summary, is the QA system within this program/unit fully YES NO
functional, with evidence that all relevant loops are closed?
(for Initial Program Accreditation only)

Q8A In summary, based on Q 1-7, is the proposed QA system YES NO
within this program/unit appropriate?
88
Please add any comments on the efficiency and effectiveness of the QA Office and/or the QA system, as
implemented in this program / unit.
89
Form 03
ERT VISIT EVALUATION
Dear External Review Team Member,
To assist the CAA in improving its Institutional Licensure and Program Accreditation processes and
services, the CAA appreciates your feedback on various elements of the on-site visit in which you have just
participated.
Institution
Type of the Visit
Dates of the Visit
Name of Commissioner
PART A: The “Standards”

To ensure the appropriateness and the utility of the Standards in helping achieve Quality Assurance, the
CAA appreciates your feedback by rating each of the following using the following scale:
5 (Very Good), 4 (Good), 3 (Satisfactory), 2 (Unsatisfactory) and 1 (Poor).
No. Criteria 5 4 3 2 1
1 Overall quality of the Standards as compared to
internationally recognized standards
2 Inclusivity of the Standards to foster institution-
wide quality assurance
3 Rigor of the Standards to ensure high quality
academic programs
4 Depth of the Standards to guide institutions in the
development and implementation of effective
quality assurance systems and processes
5 Clarity of the Standards and ease of use
90
Please note any comments on the above issues, or suggestions which the CAA should consider for further
improvement of the Standards and its operation.
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
......
PART B: Arrangements and implementation of the on-site visit
Please rate each of the following using the following scale:

5 (Very Good), 4 (Good), 3 (Satisfactory), 2 (Unsatisfactory) and 1 (Poor).
No. Criteria 5 4 3 2 1
1. Initial contact and preliminary information on
the visit
2. Usefulness of the Manuals for External Review
Teams
3. Travel arrangements within UAE
4. Travel arrangements to/from UAE
5. Organization of the visit schedule
6. Usefulness of Preparation Day
7. Time allotted for overall visit
8. Usefulness of Template
9. Guidance from Commission on writing of the

Report
10. Overall guidance from the Commissioner
Please note any comments on the above issues, or suggestions which will improve the effectiveness of
the on-site visit. The Director of the CAA will be pleased to receive any additional comments of a more
confidential nature (My.baniyas@moe.gov.ae)
91
Name of the ERT
Member: (optional) …………………………………… Date: ...............................
92
Form 04
PROGRAM DESCRIPTION
INSTITUTIONAL INFORMATION
Institution Name
College/ Department
Contact details of
Department Chair/ Name Title
Program Coordinator
Tel
Email
No
PROGRAM INFORMATION
Program reviewed for
Initial Accreditation Renewal of Accreditation
(Tick as applicable)
Date of the Visit
/ / to / /
(DD/MM/YYYY)
Associate Degree/Diploma Higher Diploma Bachelor's degree

(Level 5) (Level 6) (Level 7)
(2) yrs (3) yrs (4) / (5) yrs
Program level
Postgraduate Diploma Master's degree Doctorates

(Level 8) (Level 9) (Level 10)
(1) / (2) yrs (1) / (2) yrs (3) yrs
Program Title in English
(as it should appear on student
transcripts/ CAA website, and
as approved by the Institution)
Program Title in Arabic
(as would appear on student
transcripts/ CAA website, and
as approved by the Institution)
List concentrations in the
proposed program 1:
(in English and for
undergraduate programs
only/if applicable) 2:
List concentrations in the

proposed program 1:
93
(in Arabic)
2:
VERIFIED & SIGNED:

Commissioner
Additional
Comments /
Notes
94
Form 05

Policy Statement and Declaration Form - Ethical Obligations of External Review
Team Members and Consultants
Rationale
Integrity, essential to the purpose of higher education, functions as the basic contract defining the
relationship between the Commission and each of its licensed institutions. It is a relationship in which
all parties agree to deal honestly and openly with their constituencies and with one another. Without
this commitment, no relationship can exist or be sustained between the Commission and its licensed
institutions or other institutions in the UAE. Commissioners, Commission staff, External Review
Team (ERT) members, consultants, or others associated with the Commission are expected to make
a conscientious application of the Standards for Institutional Licensure and Program Accreditation
(2019). The Commission’s requirements, policies, processes, procedures, and decisions are predicated
on integrity.
Institutional licensure and program accreditation in the United Arab Emirates are based upon a review
process that requires international experts to review institutions and programs and to make
recommendations about their licensure or accreditation. In order to maintain the credibility of those
decisions, not only must the Commission hold institutions accountable for integrity governing all
aspects of their operations, but it also must ensure that reviewers responsible for making
recommendations maintain the highest level of integrity in all matters dealing with the decision-
making process of the Commission and in matters dealing with institutions or programs under review.
Integrity of the process mandates at least the following ethical obligations and understandings.
Confidentiality
All External Review Team (ERT) members and consultants, or others working with the Commission,
must maintain complete confidentiality and conduct themselves with professional integrity in all
licensing and accreditation activities and decisions. Confidentiality applies to all levels of the review
process. Confidentiality applies to all documents, correspondence, and discussions relative to all
phases of a review.
Unless the disclosure of such information is appropriate as a part of the Commission’s work with a
specific institution, ERT members, consultants, or others working with the Commission may not
disclose to any person or persons other than Commissioners and Commission staff the following:
1. information about an institution or an institution’s program scheduled for review, including the
analysis of institutional materials; information gained from meetings; committee discussions
before and during the review; and the resource material;
2. information distributed as part of Commission staff memos and oral comments by staff ;
95
3. decisions of the ERT or the Commission; or
4. the rationale for a decision of the Commission pertaining to an institution.
Without a commitment to confidentiality by ERT members, consultants, or others working with the
Commission, in all aspects of the review process, they will not be able to freely execute their
responsibility to conduct themselves with professional integrity in accreditation or licensing activities
and decisions.
Conflict of Interest
The Commission for Academic Accreditation seeks to ensure that the personal or professional
obligations or interests of ERT members, consultants, or others working with the Commission do not
interfere with their ability to conduct their duties in a fair and impartial manner. This policy statement
defines those areas that the Commission considers to represent an actual or potential conflict of
interest. The Commission’s purpose in defining these parameters is to:
 maintain credibility in the licensure and accreditation process and confidence in its
decisions;
 assure fairness and impartiality in decision making;
 avoid allegations of undue influence in the licensure and accreditation process; or

relationships that might bias the actions, deliberations, or decisions of the Commission;
conflicts that would impair judgment; and circumstances that could interfere with an
individual’s capacity to make objective, detached decisions; and
 assure opinions free of self-interest and personal bias.
If an ERT member or consultant is a candidate for a position with an institution, he or she must
immediately notify the Commission and must not be involved in any Commission activity related to
that institution.
Any professional consulting arrangement or other employment arrangements between ERT members
or consultants and institutions may be made only with the approval of the Director of the Commission.
In addition, the Commission relies on the personal and professional integrity of individuals
to refuse any assignment in which an actual or potential conflict of interest exists. If an unanticipated
actual conflict of interest develops, the ERT member or consultant should withdraw at that point.
In all cases, it is the responsibility of the ERT member, consultant, or other person associated with
the Commission, to determine whether or not an outside relationship does in fact constitute a conflict
of interest.
This policy was based on the Middle States Commission for Higher Education Conflict of Interest for Employees and the Commission on Colleges of
the Southern Association of Schools and Colleges Ethical Obligations of Commissioners statements: 7/7/2009.
96
Institution
Type of the Visit
Dates of the Visit
DECLARATION FORM
CONFLICT OF INTEREST STATEMENT
External Review Team Members and Consultants
I hereby certify that I have read the policy statement of the Commission for Academic
Accreditation regarding Ethical Obligations of External Review Team Members
and Consultants. I further certify that I have no conflict of interest or potential conflict
of interest related to my engagement with the Commission or related to any of the
institutions licensed by or under the aegis of the Commission that would prevent me
from providing a fair, impartial and unbiased opinion in connection with my work.
In the event any conflict of interest or potential conflict of interest may arise during the
course of my engagement with the Commission, I will promptly notify the Director of
the Commission and will dissociate myself from any Commission work related to that
institution.
Name (printed) …………………………………………………………
Signature ……………………………………….
Date: …………………………………………..
97
Form 06
INSTITUTIONAL LICENSURE RECOMMENDATION
Institution
Type of Licensure
Dates of the Visit
We, the undersigned members of the External Review Team of the above Institution recommend the
following:
a. Subject to the Council of Commissioners approval of the above-mentioned institution being in

compliance with the Standards for Institutional Licensure and Program Accreditation, and with
all of the requirements contained in the attached report, the External Review Team recommends
that the institution be initially licensed/ licensed.
b. Subject to further review by the Council of Commissioners, the External Review Team
recommends that the institution be put on probation.
c. Subject to further review by the Council of Commissioners, the External Review Team
recommends that the institutional licensure be denied.
Name Signature Date

1.
……………………………………… …………………………… ……………………

2.
……………………………………… …………………………… ……………………

3.
……………………………………… …………………………… ……………………

4.
……………………………………… …………………………… ……………………

5.
……………………………………… …………………………… ……………………
98
Form 07
PROGRAM ACCREDITATION RECOMMENDATION

Institution
Name of the
Program
Dates of the Visit
We, the undersigned members of the External Review Team of the above Program recommend the
following:
a. Subject to the Council of Commissioners approval of the above mentioned program being
in compliance with the Standards for Institutional Licensure and Program Accreditation,
and with all of the requirements contained in the attached report, the External Review
Team recommends that the program be initially accredited/re-accredited.
recommends that the program be put on probation.
recommends that the program be denied.
Name Signature Date

1.
……………………………………… …………………………… ……………………

2.
……………………………………… …………………………… ……………………

3.
……………………………………… …………………………… ……………………

4.
……………………………………… …………………………… ……………………

5.
99
……………………………………… …………………………… ……………………
6……………………………………… …………………………… ……………………
100
Form 8
INSTITUTIONAL AUDIT RECOMMENDATION
Institution
Dates of the Visit
We, the undersigned members of the External Review Team of the above Institution recommend the
following:
a. Subject to the approval by the Council of Commissioners, the above-mentioned institution is

regarded as being in compliance with the Standards for Institutional Licensure and Program
Accreditation.
recommends that the institution be issued a warning.
recommends that the institution and all of its programs be placed on probation.
d. Subject to further review by the Council of Commissioners, the External Review Team
recommends that the institution be closed.
Name Signature Date

1.
……………………………………… …………………………… ……………………

2.
……………………………………… …………………………… ……………………

3.
……………………………………… …………………………… ……………………

4.
……………………………………… …………………………… ……………………

5.
……………………………………… …………………………… ……………………
101
Form 9
APPLICATION FOR INITIAL/ RENEWAL OF

INSTITUTIONAL LICENSURE
in English
Institution Name
in Arabic
Location of the Main Campus

of the Institution
Date of submission
/ /
(DD/MM/YYYY)
If applying for Renewal of
Institutional Licenture, state the
date of expiration of / /
Institutional Licensure
(DD/MM/YYYY)
Name Designation
Details of Institution Contact
Person Tel
Email
No
Is the Institution affiliated with or does it intend an affiliation with another institution in the UAE or abroad? If so,
please name the institution and provide the address and contact information:
Signed: (CEO) __________________________________________
102
Form 10
APPLICATION FOR INITIAL/ RENEWAL OF

PROGRAM ACCREDITATION
Institution Name
Location of offering the

Program- Campus (s)
Date of submission
/ /
(DD/MM/YYYY)
If applying for Renewal of

Program Accreditation state the
/ /
date of expiration of Program
Accreditation (DD/MM/YYYY)
Name Designation
Contact details of Program
Coordinator
Tel No Email
Name Email
Contact details of the Chief
Executive Officer (CEO)
Tel No
in English
Title of the
program
in Arabic
Language of instruction
Length of the program

(for regular full-time students)
Is the program affiliated with or does it intend an affiliation with another institution in the UAE or abroad? If so, please
name the institution and provide the address and contact information:
103
Signed: (CEO) __________________________________________
104
Form 11
PROGRAM COMPLIANCE INDICATORS

WITH THE STANDARDS FOR Institutional LICENSURE
AND Program ACCREDITATION 2019
Institution
Program
Commissioner
Dates of the Visit
QUALITY ASSURANCE (STANDARD 2)
Q 1. Does the Institutional Effectiveness Office participate in the regular assessment of

program effectiveness? YES NO
Q 2.
Is the program benchmarked against best local and international practices?
YES NO
Q 3. Does the program have an active external Advisory Board (with designated
membership that represents relevant stakeholders from the community)?
YES NO
EDUCATIONAL PROGRAM (STANDARD 3)
Q 4. Is there an ongoing rationale for the program which demonstrates that it

continues to fill a need both for students and society?
YES NO
Q 5. Does the Institution maintain course files for the program that include all of the
elements required in accordance with Annex 16: Course Files of the Standards? YES NO
Q 6. Do the program outcomes align with the defined level of the degree or award as
specified in the QFEmirates ?
YES NO
Q 7. Is there a matrix relating program and/or any concentration outcomes to the
learning outcomes of the courses?
YES NO
Q 8. Are there detailed syllabi for all courses, including general education courses that
comply with the requirements in Annex 13: Course Syllabi?
YES NO
Q 9. Does the mode of delivery enable the achievement of course and program
learning outcomes?
YES NO
105
Q 10. Does the program utilize appropriate methods to authenticate student work and to
record performance?
YES NO
Q 11. Is the institutional policy regarding optimal class sizes applied in the context of the
proposed program and its constituent courses?
YES NO
RESEARCH AND SCHOLARLY ACTIVITIES (STANDARD 4)
Q 12. Is there evidence of the scholarly and research productivity of the faculty
members assigned to the program?
YES NO
Q 13. Are there appropriate policies and procedures governing faculty research?
YES NO
Q 14. Is there an appropriate level of support, documented in a budget, for research?
YES NO
FACULTY AND PROFESSIONAL STAFF (STANDARD 5)

Q 15. Does the program have appropriately qualified faculty, who teach within their
subject area?
YES NO
Q 16. Does the faculty workload meet the requirements of the Standards?
YES NO
Q 17. Does the percentage of part-time faculty used in the program meet the
requirements of the Standards?
YES NO
STUDENTS (STANDARD 6)
Q 18. Do the requirements for regular admission, as well as those for provisional
admission, comply with the requirements of the Standards?
YES NO
Q 19. Does the institution implement procedures required to monitor and enforce
academic integrity, including detection of plagiarism?
YES NO
Any other comments :
106
Form 12
REVIEW COMPLETION ‫إنجاز التقييم‬
Assignment Order No ( ‫) رقم شهادة اإلنجاز‬

(to be filled-in by Admin Staff) ( ‫) يعبأ من قبل اإلدارة‬
Administrative decree: )‫) رقم القرار اإلداري‬
Filled by the commissioner
Institution (‫) المؤسسة‬:
Program Name (‫) اسم البرنامج‬:

(Please type full title of program; leave blank if it is licensure review )
Name of Commissioner (‫)اسم المفوض‬:
TYPE OF WORK ‫نوع العمل‬
Program Accreditation Institutional/ Program Audit Interim/ Special Visit

Type of On-site Visit: Institutional Licensure
)‫(اعتماد برنامج‬ )‫ برنامج‬/‫(تدقيق مؤسسة‬ )‫(زيارة خاصة‬
)‫(ترخيص مؤسسة‬
) ‫( طبيعة الزيارة‬
Initial Renewal
Initial Renewal
On-site Visit Distance Review Response Review Substantive Change

Completion of work for: )‫(زيارة ميداني ة‬ )‫(مراجعة عن بعد‬ )‫(مراجعة رد المؤسسة‬ )‫(تغيير جوهري‬
)‫(العمل المنجز‬ 1st 2nd 3rd
Name of Reviewer )‫ (اسم المق ي ّم‬:
Role of Reviewer)‫(دور المق ي ّم‬: )‫ (رئيس فريق‬Chair of ERT ERT Member ) ‫( مق ي ّم‬
HONORARIUM PAYMENT ‫المكافأة المالية‬
Actual Working Day/ Distance Review

) ‫ المراجعة عن ب ُعد‬/ ‫( أيام العمل الفعلي‬:
(Total count from ARRIVAL date to END date of
visit; add ONE extra day for the Chair)
‫) ا لعدد اإلجمالي من تاريخ الوصول إلى نهاية تاريخ الزيارة باإلضافة الى‬
) ‫يوم واحد لرئيس الفريق‬
APPROVAL DETAILS ‫تفاصيل االعتماد‬
Approved By ) ‫ (التواقيع المعتمدة‬: Commissioner )‫(المفوض‬ CAA Director )‫(مدير ال مفوضية‬
Date of Approval (DD/MM/YYYY):

)‫السنة‬/‫الشهر‬/‫تاريخ االعتماد (اليوم‬
107
Form 13
EXTERNAL REVIEW TEAM BANK INFORMATION

‫البيانات البنكية للمقَيم الخارجي‬
Account Name (Must be under personal name)
Account No.
Bank Name (Only one bank)
Bank Address
IBAN or Routing No.

SWIFT Code
108
‫‪Form 14‬‬
‫‪MOE Vehicles Order Form‬‬ ‫استمــارة طلـــــب مركبات‬

‫‪Application Date‬‬ ‫تاريخ تقديم الطلب‬
‫‪Employee Name‬‬ ‫االســـــــــــــــــــم‬
‫‪Position Title‬‬ ‫الــوظـيـفـــــــــــة‬
‫‪Department‬‬ ‫اإلدارة‬
‫‪ID Number‬‬ ‫الرقم الوظيفي‬
‫‪Number of transferees‬‬ ‫عدد المنقولين‬
‫‪Going from/ to‬‬ ‫الــذهــاب من‪ /‬الى‬

‫‪Day /Date & time of going‬‬ ‫اليوم‪ /‬التاريخ ووقت الذهاب‬
‫‪Reason‬‬ ‫الـــســـــبــــــب‬
‫‪Coming from / to‬‬ ‫العودة من ‪ /‬الى‬
‫‪Day/ Date & time of coming‬‬ ‫اليــوم والتــاريــخ ووقت العودة‬
‫‪Phone‬‬ ‫الهـــاتــــــــــــــف‬
‫توقيع الموظف‬ ‫توقيع مدير اإلدارة‪/‬رئيس القسم‬
‫‪Employee Signature‬‬ ‫‪Division Manager/Section Manager Signature‬‬
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
‫الستخدام قسم الخدمات المركزية فقط‬
‫‪CENTRAL OFFICE SERVICES SECTION USE ONLY‬‬
‫‪Not Approved‬‬ ‫عدم الموافقة‬ ‫‪Approved‬‬ ‫الموافقة‬
‫‪Date:‬‬ ‫التاريخ‪:‬‬
‫المالحظات‪:‬‬
‫‪ ‬تقديم استمارة طلب المركبة كحد أدنى قبل يومين عمل من موعد المهمة‪ ،‬وذلك لتفادي التأخير في النقل ولتقديم أفضل الخدمات‪.‬‬
‫‪ ‬تقديم الطلب قبل الساعة ‪ 2‬ظهراً‪ ،‬وفي حالة عدم االلتزام بذلك فلن ينظر في الطلب‪ ،‬وفي حالة الطلبات الطارئة يرفق ما يثبت ذلك‪.‬‬
‫‪109‬‬
Form 15
VISIT DETAILS FORM
VF:…………..
Institution Program
Location Visit Dates

(including the arrival day)
Contact at the Institution Email
ERT Details 1 (Chair) 2 3 5 (Commissioner)

Name & Designation
Nationality
( Specify if visa required)
Physical Address:
Telephone
(Work & Mobil)
Email
Specify if Letter of
Invitation required
Nearest Airport
(at Origin)
Travel Date (at Origin)
Date of Arrival
(Specify Arrival Airport)
110
Date of Departure
(Departure Airport)
Specify if Meet & Greet
service required
Accommodation:
City
Check-in Date
Check-out Date
Room Type
Meeting Room Requirements None. All meetings will be held in the institution
Logistics Date From To Time Comments
Day 0 (Arrival Day)
Day 1 (Preparation)
Day 2
Day 3
Day 4 (Exit)
Any other special arrangements (please specify):
Name of Commissioner: Director of CAA: Dr. Mohamed Yousif Baniyas
Signature: Signature:
111
Form 16
Visit Schedule
Purpose of the visit
Name of the institution
Period of the visit
External Review Team
Prof. ….…. (Chair)

Position
Institution
Country
Prof. ……. ……
…..
Commissioner
Prof. ……….
112
Saturday - Day 0: Arrival Day
No ERT activities planned.
Sunday - Day 1: Preparation Day/ Meeting with Senior Leadership

8:30 AM ERT departs hotel for institution campus
9:00 AM – 11:00 AM Preparation meeting for ERT at the campus
This day will be preparation, including orientation, review of
documents, and writing. All appropriate institutional and
program documentation should be available.
Note to institution Staff: The base room on the campus should
include internet access and a computer workstation with printer
capability. Should also include the institutional documentation
on this program including course files (including textbooks) for
all courses offered in the program (including general education,
electives, and any courses offered by other
departments/colleges), the Self-Study, Faculty Handbook, Staff
Handbook, Student Handbook, Catalog, Quality Assurance
Manual, Policies and Procedures Manual, Fact Book, Strategic
and Action Plan(s) – institution level, Strategic and Action Plan
– college/department level, Organizational Chart (with names
of current appointees and vacant positions) for both institution
and college/department level, assessment reports, assessment
information, course schedule for the last two semesters, current
study plan for the program and related programs, faculty roster
for full-time and part-time for the college/department
categorized by program (detailing name, rank, highest degree
earned, specialty, joining date), detailed faculty
working/teaching assignment for the college/department
categorized by program (specified courses, number of sections,
credit hours, admin responsibilities, and total load) for the last
two semesters, list of faculty publications in the program for the
past two academic years, actual expenditures on research for
the program in the past two academic years, complete faculty
files, complete staff files (who are related to the program), list
of books and current journals (related to the program), list of
current students in the program (detailing name, student
number, admission date, TOEFL score, TOEFL score date,
number of credits enrolled, number of credits passed, and
GPA), institutional student population for the current academic
year categorized by program/college, student appeals for the
113
last two semesters, minutes of college/department committees,
advisory board, etc. All required documents should be available
in the base room.
Provision for coffee, tea, and light snacks is appreciated
throughout the visit.
11:00 AM - 11:30 AM ERT meets with the President
Note to institution: This is an introductory meeting; the ERT
expects a brief presentation about the institution.
11:30 AM - 1:00 PM ERT interviews with the Chair of the program and Dean of the
college.
Note to institution: The specific of the presentations by the
Chair and/or Dean are the responsibility of the institution.
Given that this will be a tight schedule, the team urges the
institution to keep overview presentations brief. The majority of
the time should be for discussions and question. The institution
shall decide on the personnel to be in the meeting.
1:00 PM ERT working lunch; no campus personnel
2:00 PM - 4:00 PM Continue preparation meeting for ERT
4:00 PM ERT returns to hotel
Monday - Day 2: Campus Workday

9:00 AM - 12:00 PM Executive session for ERT
12:00 PM - 1:00 PM Tour of campus facilities that are relevant to the program
Note to institution: This tour should include the library,
laboratory facilities, and other facilities associated with the
program. Need not to be a comprehensive tour of the whole
campus.
1:00 PM - 2:00 PM ERT lunch with representative faculty/staff
Note to institution: This lunch is designed as, in part, a social
event and, in part, as an opportunity for the ERT to interact with
individuals whom they might not otherwise have the chance to
interview but have an important role for the program.
2:00 PM - 4:00 PM ERT interviews faculty
Note to institution: This interview time is for faculty interviews.
Also, provide faculty files and a list of current faculty in the
department/college along with their credentials and
114
teaching/administrative loads. The ERT will conduct interviews
in parallel.
Tuesday - Day 3: Campus Workday

9:15 AM - 10:30 AM Executive session for ERT
10:30 AM - 12:00 PM ERT interviews admin staff
Note to institution: This interview time is for staff interviews.
The ERT will need interview time with: (1) Head of Quality
Assurance; (2) Head of Student Services; (3) Head of Research;
(4) Head of IT Services; (5) Head of Library; (6) Head of
Finance; (7) Head of Human Resource; and (8) Head of
Admission and Registration.
The ERT will conduct interviews in parallel. This might also
include follow-up interviews as requested through the
Commissioner.
12:00 PM - 1:00 PM Executive session for ERT
1:00 PM - 2:00 PM Working lunch for ERT; no campus personnel
2:00 PM - 4:00 PM Students, alumni, Advisory Board, and employers interviews
Note to institution: These are particularly important sessions
for an accreditation visit. The institution should arrange for a
representative sample of students and alumni of the program
(one session) and members of the external advisory board and
employers of the program (a second session). Sessions should
be no more than 45 minutes.
4:00 PM ERT leaves for hotel
Wednesday - Day 4: Exit Day

9:00 AM -12:30 PM Working executive session for ERT
1:30 PM - 2:00 PM Exit meeting
Note to institution: This meeting includes President, Dean,
Chair, and others as invited by the institution.
115
This exit meeting will be an overview of the findings of the ERT;
there will not be time for discussion other than for purposes of
clarification. During this exit meeting, the Commissioner will
present an overview of “next steps” for the institution as part of
the accreditation process.
The format for the meeting will begin with opening remarks by
the Commissioner, the presentation by the ERT Chair and a
brief closing by the Commissioner. The President may wish to
make very brief final remarks, but the exit meeting is not the
time for questions or begins responding to the report. The
institution shall decide on the personnel to be in the meeting.
2:00 PM ERT departs for hotel
116
Form 17
Report of the External Review Team
Period of the visit
Prepared for the

Prof. ….…. (Chair)

Position
Institution
Country
Prof. ……. ……
…..
Commissioner
Prof. ……….
117
Notice
This is a confidential statement from the External Review Team of the Commission for Academic
Accreditation of the Ministry of Education of the United Arab Emirates. The findings of the External
Review Team Committee reflect its observations at the time of the visit and relate to the Standards for
Institutional Licensure and Program Accreditation, 20191[hereinafter referred to as the Standards], and
the Procedural Manual for Initial/Renewal of Institutional Licensure [PMIIL/PMRIL]. This report is for
internal use only and is not for release except as allowed by policies of the Commission for Academic
Accreditation.
Introduction
[Note to ERT: The introduction will be expanded “on site” and tied to the specific institution.
I will plan on drafting this on behalf of the ERT]
An External Review Team (hereafter ERT) visited the (Institution Name and its acronym) from xx to
xx, to evaluate the Application (hereafter the Self-Study/Application) for Initial/Renewal of Licensure
of the (the institution name). The exit interview was held on (date). This report presents the
observations and recommendations of the ERT.
...
…..
This report contains the observations of the ERT based on the information submitted to it in the Self-
Study / Application and associated materials, other documentation conveyed to the ERT during the
visit, oral presentations, and information resulting from in-depth discussions. The report also includes
Requirements, which are actions (the institution acronym) must take in order for the institution to
receive Licensure, as well as Suggestions that, although not binding, must be considered by (the
institution acronym).
Institution Report
[Note for ERT: There are aspects of the Standards which are more applicable to Licensure or
the Renewal of Licensure (both of which consider the entire institution) than to Initial
Accreditation or of Renewal of Accreditation. That has meant that in the template below, I
have eliminated some of the sections as not needing your attention during this visit. For initial
licensure we are looking at promises; for renewal of licensure we are looking at results.
Some division of labor seems appropriate for the review. What has worked in the past is to
assign the broad institutional sections (support areas) to one of you and divide the institution
areas by specific expertise. If each of you will write on the designated sections, and give
118
particular attention to those, the report should come together nicely. As Chair, (Name of the
Chair) will have responsibility for bringing the narratives together (including what I will do on
the introduction; I will be happy to assist on all of this if it will help).
In terms of using this template, it has worked well if you simply do your writing on this. It is a
Word document. It is advisable that you do most of the initial writing before the visit based on
your reading of the submitted material and comparing compliance with the Standards, and then
raise some questions that will need to be answered on site during the visit. Later on, you will be
able to polish your write-up and finalize your assigned sections. Given that, this is an institution
in which each of you has expertise in it, some division of labor seemed appropriate. I’d ask
(Name of the Chair), as Chair, to review the assignments and determine whether or not any
changes are appropriate. The design of the assignments is to focus your attention on particular
areas and facilitate the writing process.
As to using the template, there is no need to worry about the extras at this point. There is no
need, for example, to bold face certain sections italicize, etc. If you are quoting a text, obviously
put it in quotation marks and give a citation. I will work through the document during the
editing phases to insert bold face, italics, underlines, bullets, etc. where they are needed.
As to assignments, please take the lead on those sections with your name attached to them.
(Name of the Chair), as Chair, may want to make changes in assignments, just let me know.
Unless otherwise indicated, you would have responsibility to write the narrative for the entire
section as noted.
As a committee goal, we should plan on having our report fully merged by late afternoon on
Day 3 so that we can spend the morning of Day 4 (Last Day) fine tuning, going over what it is
that we want to say at the exit meeting, completing required CAA forms, etc. If you are able to
get the initial merged document to me by the third day, I can begin the editorial process and
begin attempting to make the document sound like “one voice.” Some of that occurs in the
initial edit; most will take place after you return to your respective homes and after I get back
to the office. From the draft schedule/itinerary for the visit, you will know that we will be busy;
the more writing that you can do in advance of your arrival (writing that would be based on the
documents which already sent to you), the better.
Please also note the following:
 Your narrative is a statement of compliance and/or noncompliance with the issue.

Include a statement of the evidence for your conclusion (i.e. interviews, the
Application, Self-Study, one or more of the appendices, international norms, etc.) For
examples and ideas on writing the narrative, please consult the Handbook for
External Review Teams which would have been sent to you along with the institutional
documents.
119
 The “Standards” for compliance and/or noncompliance are those outlined on pages
18-23 of the Standards for Institutional Licensure and Program Accreditation, 2019.
The document is available on the CAA website. Be sure to use the appropriate
procedural manual, for initial licensure use the Procedural Manual for Institutional
Initial Licensure (PMIIL) and for Renewal of Licensure use the Procedural Manual
for Renewal of Institutional Licensure (PMRIL) which are also available on the CAA
website.
 On the template I’ve listed the broad headings from the Standards to organize your
writing. Your analysis and judgment should be inclusive of all subsections of the
Standards as appropriate to the institution.
 Although you may offer constructive commentary on each area of the template, you
must offer a summary of the documentation reviewed and the context for all
requirements and suggestions.
 Your comments may be inserted on the template and then conveyed to the Chair of
the ERT during the visit as requested.
[We will remove all of this instructional language before completing the final report]
Section 1: Governance and Management (Standard 1)
1.1 Vision and Mission
1.2 Organization
1.3 Governance
1.4 Policies and Procedures
1.5 Institutional Planning
1.6 Risk Management
1.7 Institutional Management and Administration
1.8 Multiple Campus Institutions within the UAE
1.9 Campuses of UAE Institutions in Other Countries
1.10 Branch Campuses of Foreign Institutions
120
Section 2: Quality Assurance (Standard 2)
2.1 Quality Assurance System
2.2 Continuous Quality Enhancement
2.3 Quality Assurance Unit
Section 3: Research and Scholarly Activities (Standard 4)
3.1 Strategy and Policies
3.2 Support for Research and Scholarly Activity
3.3 Collaborative Research and Scholarly Activity
3.4 Expectations for Research and Scholarly Activity
3.5 Research and Scholarly Activity Outputs
Section 4: Health, Safety and Environment (Standard 7)
4.1 Occupational Health and Safety
4.2 Facilities
4.3 Residence Halls
4.4 Technology Infrastructure
Section 5: Fiscal Resources, Financial Management and Budgeting (Standard 9)
5.1 Fiscal Resources
5.2 Student Protection Plan/Teach-out Reserve
5.3 Organization and Administration
5.4 Budgeting
121
5.5 Expenditures
5.6 Financial Management
5.7 Accounting and Auditing
5.8 Financial Reporting to the MoE
5.9 Insurance
Section 6: Legal Compliance and Public Disclosure (Standard 10)
6.1 Institution Name and Program Titles
6.2 Legal Compliance and Contracts
6.3 Public Information
6.4 Integrity and Transparency
6.5 Relationship with the MoE
Section 7: Community Engagement (Standard 11)
7.1 Community Engagement Strategy
7.2 Relationships with Employers
7.3 Relationships with other Education Providers
7.4 Relationships with Alumni
7.5 Continuous Education
7.6 Evaluation
122
Conclusions
[Note to ERT: This will be a summary statement written by the Chair of the ERT. It is often
the case that the initial draft of the conclusion is the written text for the remarks to be made at
the exit meeting. It should generally point toward whether or not you are recommending
approval of licensure, approval only if the requirements are met, or disapproval of licensure.
You should not, however, actually make a requirement in the conclusion.]
[Note to ERT: This statement is boilerplate and is the last section of every concluding
statement:]
The ERT makes its requirements in a spirit of constructive engagement, with the aim of ensuring that
the Standards are met, and to aid the (the institution acronym) in its desired objective to license the
institution.
123
Form 18
Report of the External Review Team
Period of the visit
Prepared for the

Prof. ……. (Chair)

Position
Institution
Country
Prof. ……. ……
…...
Commissioner
Prof. ……….
124
Notice
Institutional Licensure and Program Accreditation, 20191[hereinafter referred to as the Standards], and
the Procedural Manual for Initial/Renewal of Program Accreditation [PMIPA/PMRPA]. This report is
for internal use only and is not for release except as allowed by policies of the Commission for Academic
Accreditation.
Introduction
[Note to ERT: The introduction will be expanded “on site” and tied to the specific program. I
will plan on drafting this on behalf of the ERT]
xx, to evaluate the Application (hereafter the Self-Study/Application) for Initial/Renewal of
Accreditation of the (the program name). The exit interview was held on (date). This report presents
the observations and recommendations of the ERT.
...
…..
visit, oral presentations, and information resulting from in-depth discussions. The report also
includes Requirements, which are actions (the institution acronym) must take in order for the
programs to receive Accreditations, as well as Suggestions that, although not binding, must be
considered by (the institution acronym).
Program Report
[Note for ERT: There are aspects of the Standards which are more applicable to Licensure or
the Renewal of Licensure (both of which consider the entire institution) than to Initial
Accreditation or of Renewal of Accreditation. That has meant that in the template below, I
have eliminated some of the sections as not needing your attention during this visit. For initial
accreditation we are looking at promises; for accreditation we are looking at results.
Some division of labor seems appropriate for the review. What has worked in the past is to
assign the broad institutional sections (support areas) to one of you and divide the program
areas by specific expertise. If each of you will write on the designated sections, and give
125
particular attention to those, the report should come together nicely. As Chair, (Name of the
Chair) will have responsibility for bringing the narratives together (including what I will do on
the introduction; I will be happy to assist on all of this if it will help).
Word document. It is advisable that you do most of the initial writing before the visit based on
your reading of the submitted material and comparing compliance with the Standards, and then
raise some questions that will need to be answered on site during the visit. Later on, you will be
able to polish your write-up and finalize your assigned sections. Given that, this is an institution
in which each of you has expertise in it, some division of labor seemed appropriate. I’d ask
(Name of the Chair), as Chair, to review the assignments and determine whether or not any
changes are appropriate. The design of the assignments is to focus your attention on particular
areas and facilitate the writing process. As a reminder, the CAA expects our review teams to
get to the course level which will mean a close look at syllabi and some statement about the
courses. The statements might be about each course or a cluster of courses that make up the
program.
As to using the template, there is no need to worry about the extras at this point. There is no
need, for example, to bold face certain sections italicize, etc. If you are quoting a text, obviously
put it in quotation marks and give a citation. I will work through the document during the
editing phases to insert bold face, italics, underlines, bullets, etc. where they are needed.
(Name of the Chair), as Chair, may want to make changes in assignments, just let me know.
section as noted. Where I have indicated more than one name for a subsection, the thought is
that you both want to weigh in on that section and then come up with a consensus narrative.
As a committee goal, we should plan on having our report fully merged by late afternoon on
Day 3 so that we can spend the morning of Day 4 (Last Day) fine tuning, going over what it is
that we want to say at the exit meeting, completing required CAA forms, etc. If you are able to
get the initial merged document to me by the third day, I can begin the editorial process and
begin attempting to make the document sound like “one voice.” Some of that occurs in the
initial edit; most will take place after you return to your respective homes and after I get back
to the office. From the draft schedule/itinerary for the visit, you will know that we will be busy;
the more writing that you can do in advance of your arrival (writing that would be based on the
documents which already sent to you), the better.
 Your narrative is a statement of compliance and/or noncompliance with the issue.

Include a statement of the evidence for your conclusion (i.e. interviews, the
Application, Self-Study, one or more of the appendices, international norms, etc.) For
126
examples and ideas on writing the narrative, please consult the Handbook for
documents.
 The “Standards” for compliance and/or noncompliance are those outlined on pages
18-23 of the Standards for Institutional Licensure and Program Accreditation, 2019.
The document is available on the CAA website. Be sure to use the appropriate
procedural manual, for initial accreditation use the Procedural Manual for Initial
Program Accreditation (PMIPA) and for Renewal of Accreditation use the Procedural
Manual for Renewal of Program Accreditation (PMRPA) which are also available on
the CAA website.
 On the template I’ve listed the broad headings from the Standards to organize your
writing. Your analysis and judgment should be inclusive of all subsections of the
Standards as appropriate to the program.
 Although you may offer constructive commentary on each area of the template, you
must offer a summary of the documentation reviewed and the context for all
requirements and suggestions.
 Your comments may be inserted on the template and then conveyed to the Chair of
the ERT during the visit as requested.
Section 1: Quality Assurance (Standard 2)
Section 2: Educational Programs (Standard 3)
2.1 Program Planning and Development
2.2 Budgeting for Programs
2.3 Program Structure and Completion Requirements
2.4 National Qualifications Framework (QFEmirates)
127
2.5 Graduate Programs
2.6 General Education
2.7 Remedial Courses
2.8 Internship or Practicum
2.9 Teaching Methods
2.10 Student Assessment
2.11 Course Delivery
2.12 Course and Program Evaluation
2.13 Program Effectiveness
2.14 Substantive Change for Programs
Section 3: Research and Scholarly Activities (Standard 4)
Section 4: Faculty and Professional Staff (Standard 5)
4.1 Faculty Manual
4.2 Professional Staff Manual
4.3 Recruitment and Terms of Employment
4.4 Faculty Qualifications
128
4.5 Graduate Faculty
4.6 Professional Staff Qualifications
4.7 Faculty Workload
4.10 Professional Development
4.11 Employee Records
4.12 Evaluation
4.13 Code of Conduct
4.14 Disciplinary Actions and Appeals
4.15 Grievances
4.16 Graduate Assistants
Section 5: Students (Standard 6)
5.1 Catalog
5.2 Undergraduate Admission
5.3 Graduate Admission
5.4 Transfer Admissions, Transfer Credit and Advanced Standing
5.5 Recognition of Prior Learning (RPL)
5.6 Registration and Records
5.8 Advising Services
5.9 Student Activities and Publications
5.10 Student Behaviour and Academic Integrity
5.11 Student Appeals and Complaints
129
5.12 Student Handbook
5.13 Alumni
5.14 Feedback from Students
Section 6: Learning Resource Centre (Standard 8)
6.1 Learning Resource Centre Facilities and Infrastructure
6.2 Staff
6.3 Operations
6.4 Electronic and Non-electronic Collections
6.5 Co-operative Agreements
Conclusions
[Note to ERT: This will be a summary statement written by the Chair of the ERT. It is often
the case that the initial draft of the conclusion is the written text for the remarks to be made at
the exit meeting. It should generally point toward whether or not you are recommending
approval of accreditation, approval only if the requirements are met, or disapproval of
accreditation. You should not, however, actually make a requirement in the conclusion.]
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………..
[Note to ERT: This statement is boilerplate and is the last section of every concluding
statement:]
the Standards are met, and to aid the (the institution acronym) in its desired objective to accredit the
program.
130
Form 19
SUBSTANTIVE CHANGE/ DISTANCE PLAN

Institution: Program
Location: Date Assigned to

Reviewer(s)
Contact at the Email:

Institution:
ERT Details 1 2
Name &
Designation
Physical Address:
Telephone
Email ID
Remarks:
Name of Commissioner: Director of CAA: Dr. Mohamed Yousif Baniyas
Signature: Signature:
131
Form 20
INSTITUTIONAL APPEAL
Institution
Type of Appeal
Date
Rational for the Appeal:
Ground for the Appeal:
132
Evidence for the Appeal:
133
APPENDIX 11: GUIDE FOR ERT MEMBERS
Introduction
Invitation to Participate
The review calendar is drawn up by the CAA depending on the plan of submissions of applications
from higher education institutions for licensure or accreditation. Commissioners are assigned to
specific reviews and they commence a search of the ERT Register for potential members of ERTs.
Your initial contact with the CAA has been through the Commissioner assigned by the CAA to the
particular review. The nature of the review and the timing will have been explained by the
Commissioner in e-mail or telephone communication. Tentative dates will be proposed for the visit
but confirmation will follow when all ERT members and the institution are comfortable with the
proposed dates.
Typically, the duration of the onsite review is four days. This might be a day less or more based on
the nature of the institution or longer if visits to multiple sites need to be accommodated. When
feasible, the Commission will propose more than one review in a visit to the UAE. The duration of
the complete exercise will be explained in the invitation.
Team Selection
Members of ERTs are selected from a combination of sources including a “registry” maintained by
the CAA. Every effort is made to select reviewers who have considerable expertise, prior accreditation
and international experience, and are usually of professorial rank.
If you have been approached to participate as a reviewer and you are not currently on the CAA
Register of Reviewers, you will be asked to submit a brief curriculum vitae outlining your experience
and qualifications, particularly in relation to quality assurance activities. Your curriculum vitae will
be considered by the CAA’s Council of Commissioners for approval and you will receive notification
from the proposing Commissioner after this process.
Teams for accreditation reviews tend to be small, often just two external members plus the
Commissioner assigned to work with the team. They include ERT members who have been selected
for their expertise in the specific field under review.
For licensure reviews, the team may comprise several Commissioners working with two or more
external members, depending on the nature of the institution. The external members generally have a
broad institutional experience and experience of previous accreditation reviews with the CAA or other
quality assurance agencies.
134
Contact Information
When the Commissioner has completed the team membership and the dates have been finalized, an
email communication will provide details of the full ERT membership and contact information for
the CAA Commissioner, including his/her mobile phone number in the UAE.
If the CAA does not already have the information in its Register of Reviewers, you will be asked to
complete and return an ERT Visit Details Form to confirm your contact and other information. This
will be entered into the Register. You may also be asked to provide copy of the data page from your
passport and (for future payment) your bank account details, and you will be asked to sign and return
a conflict of interest declaration. Once the conflict of interest declaration is received, the Commission
will provide the ERT electronic access to the documentation of the institution and any other
documents needed for the review.
The details of the confirmed flights and hotel will be sent to you in advance of the visit.
For most communication, the best approach is to use the e-mail address of the assigned Commissioner.
Information such as links to copies of key documents e.g. the Standards and Supplementary Guidance,
Procedural Manuals, etc. are available from the CAA website https://www.caa.ae/caa/
Travel Information
The travel bookings and accommodation will be handled by one of the Commission's administrative
staff. Upon confirmation of the review visit the staff member will be in contact with you. The travel
process is outlined below:
Ticketing and Process Prior to Arrival
a) As soon as possible after confirmation of your participation, please send your passport data
page as a scanned document. Send as an e-mail attachment. The entire data page must be
clearly visible. It is important to note that you need to have six months remaining on your
passport in order to gain entry to the UAE.
If there is a problem with your passport, please contact the Commissioner immediately.
b) Please confirm the name of the airport and city closest to your institution/home for starting the
journey. If you have flight preferences, please send those to the CAA travel officer along with
your e-mail contact and telephone number. It cannot be guaranteed that your preferences will
be met as the CAA will normally seek the most economic business-class airline ticket with
due consideration for the route, timing, and quality of the carrier.
c) A draft of the flight itinerary will be sent to you. Please confirm that this is suitable. You need
to respond to the confirmation request promptly as the requested flights are usually ‘held’ for
a very limited period.
d) All bookings must be done by the Commission. There are no arrangements for reimbursement
of ticket costs if booked by reviewers.
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e) Where available, the CAA covers the cost of Business Class air travel. The CAA does not
reimburse Business Class rates for Economy Class tickets.
f) A copy of your e-ticket will be sent to you by the CAA travel officer.
Other Travel Issues
a) Transportation to and from the higher education institution within the UAE is provided by the
CAA.
b) Information on UAE entry visa requirements can be found at
a. https://www.mofa.gov.ae/EN/ConsularServices/Pages/Visa-Information.aspx
b. Where necessary, the CAA makes application for reviewers’ entry visas. It is important
that reviewers who need to have an entry visa issued provide passport and travel
information to the CAA in good time as visa applications place delays in the process
and are occasionally denied.
c) It is possible for a member of an ERT to either arrive one or two days early or to delay a day
or two in departure. Team members do this on occasion to see more of the UAE. Costs for
extra nights of lodging and/or meals are borne by the reviewer; the CAA can make adjustments
to the flight schedule to accommodate these additional travel needs but must be informed of
any special requirements well in advance.
d) The CAA does not provide insurance cover for your travel or your stay in the UAE. Reviewers
are advised to determine what cover they may already have and to make their own
arrangements if necessary.
On Arrival
a) If there is a delay in your arrival, please call or e-mail the Commissioner and the CAA travel
officer assigned to the visit.
b) The ground transportation, pre-arranged through the airline or the CAA travel agent, will take
you to the hotel. Most of the hotels used by the CAA are within a short taxi ride of Dubai or
Abu Dhabi airports. If any problems arise, please call the Travel Agent. Contact details are to
be found on the flight itinerary.
Departure
a) Information on your flight departure will have been communicated to you earlier through your e-
ticket. Changes in your transportation to the airport should be made through the travel officer at
the CAA.
b) On the last day of the visit, you should review the scheduled time for transportation to the airport
to ensure adequate time for check-in and security clearance.
c) If necessary, have the hotel concierge confirm your transportation pickup time with the
transportation company or airline.
d) When checking out of the hotel, be certain to pay for all incidental expenses not chargeable to the
CAA.
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Hotel
a) Hotels used by the CAA are normally five-star rated and have a good range of facilities and
services. The CAA attempts to book hotels that are in close proximity to the institution/s being
visited.
b) Room bookings will be in your name and will include the night of departure, if required for a late
checkout.
c) You will be sent a copy of the hotel bookings. Please check that the dates tally with other
information that you have received regarding duration of the visit.
d) You will need to present identification (your passport) and a credit card for any excess charges
when checking in to the hotel.
e) The CAA will cover accommodation, Internet access, tourist fees and taxes, and three items of
laundry per day. Breakfast and evening meals (excluding alcoholic drinks) are included but lunch
is not, as this is provided by the higher education institution during the visit. On arrival at the
hotel, please check with reception what is and is not covered (including any limitation on the cost
of evening meals) to ensure that there are no misunderstandings leading to unanticipated expenses
charged to you. You will need to settle your own bill for the additional expenses before leaving
the hotel.
f) The electric voltage is 240 Volts. Modern laptops do not require voltage adapters but a plug socket
adapter may be needed (the three-pin MK system used in most hotels). Most hotel rooms provide
irons, hair dryers, etc.
Monetary Matters
a) Team members will receive an honorarium payment for each day of the visit plus the arrival day.
The honorarium is currently set at 2,000 Dirhams (approximately 543$ US) per day. An additional
one-day payment is made to the ERT Chair. This is paid by electronic bank transfer after the visit
and agreement of the review report.
b) Additional honorarium payments may be made to ERT members if follow-up work is required on
the report such as an evaluation of an institutional response to the report.
c) Following the invitation to participate in the review, the Commission staff will request your bank
details so that the honorarium can be transferred to your specified bank account after the visit.
This method of payment is necessary under the UAE’s Ministry of Finance regulations.
The following information must be provided to the Commission:

Bank Name:
Bank Address:
Account Name:
Account No:
IBAN or Routing No:
SWIFT Code:
d) The UAE currency is the Dirham (AED). The Dirham is pegged to the dollar. One US dollar is
equivalent to 3.68 Dirham. Money exchange centers are available throughout the major cities and
at all hotels. The latter typically provide a less favorable rate than money exchange centers. There
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are also numerous ATM machines that will take most international credit cards. There are often
fees associated with the use of credit cards outside of the country in which they were issued.
e) If you are planning to use your credit card in the UAE, it is advisable to contact your credit card
company prior to the visit to inform them of your anticipated visit to the UAE.
f) Tipping is not obligatory in the UAE but is customary. Please do so at your own expense. Any
amount in the range of 10 Dirham or more is acceptable.
g) The CAA discourages institutions from giving gifts. Some institutions will, however, given a
token bag or a souvenir of the visit. It is appropriate to accept the gift with thanks. If you do not
want to take the gift with you on your return flight, please give it to the Commissioner.
Dress
a) You are encouraged to check the internet for local weather. Everything is air- conditioned, so a
jacket/sweater is advisable, even though you are not likely to use it on the street. Light clothing is
appropriate. Although there are no stringent rules for women's casual apparel, it is recommended
that blouses have sleeves and skirts fall below the knees.
b) During the on-site visit, more formal business attire is appropriate as meetings will be held with
college/university officials, faculty, students and employers. Suits or sport coats and slacks, shirts
and ties are the order of the day for men. Business suits or suitable business attire are suggested
for women.
c) The hotel will normally have a gym and pool so consideration might be given to clothing for
exercising and/or swimming.
Onsite Activities
a) The CAA discourages institutions from hosting evening activities or special activities which make
it more difficult for the ERT to accomplish its primary purposes. Individual team members should
not agree to social functions other than those arranged through the Commissioner.
b) Most team members find that a portion of their evenings will be spent in consultation with other
team members and/or in writing portions of the report. The nature of the onsite work is such that
writing time can sometimes be limited.
Some Protocol
a) Greetings at first meeting may or may not involve handshaking. Typically, the National women
will not shake hands. If the woman initiates a handshake, you can follow through.
b) Sitting with crossed legs is usually one of our most comfortable positions. However, to some
individuals having the sole of the foot facing toward them is an insult.
c) Photography is allowed except for certain restricted places, so long as you do not photograph
females before asking their permission. There is generally no problem with taking pictures of men.
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The Visit
Summary Roles of the ERT
Accreditation Reviews
In the case of initial accreditation reviews, the ERTs are expected to provide a thorough review of the
proposed program which is being accredited and the associated resources and support services.
In cases of renewal of accreditation reviews, the ERT will verify the evidence presented in the
application and supporting materials, that the program and supporting services are routinely evaluated
and the results of evaluation are used in the continuous improvement of the program. The ERT will
make judgements as to whether the program is delivered in full compliance with the Standards. The
review will be undertaken in the context of the 2019 Edition of the Standards and the ERT report
writing will be in relation to those Standards.
Licensure Reviews
In the case of initial licensure reviews, the ERTs are expected to verify that the submitted
documentation meets the requirements of the Standards and that the institution has policies and
procedures in place that are appropriate to keep the institution operating within the criteria of the
Standards once it is approved for establishment and operation.
In renewal of licensure reviews, the ERT will verify the evidence presented in the application and
supporting materials, that the institution is operating within its own approved policies and procedures
and that these have been maintained in full compliance with the Standards.
In reviewing the program or the institution as a whole, ERT members are expected to use their best
professional judgment with regard to whether or not an institution complies with the Standards. The
judgment should not be based on a comparison to their own institution, but rather placed in the context
of international best practice. In the writing of the narrative it is expected that the team will offer
examples and evidence to support the judgments.
Team Chair
Each ERT will have a designated Chair. The role of the Chair is to ensure that writing assignments
are appropriate and are completed in a timely manner, guide the interview process, serve as
spokesperson for the team during the exit conference, and to work closely with the Commissioner to
ensure that the logistics of the visit are smooth. Team Chairs tend to be selected from individuals who
have served the CAA during prior visits.
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Pre-visit Documents
a) An itinerary for the visit will be provided by the Commissioner as early as possible after
confirmation of the membership of the team.
b) All review materials will be sent to the ERT members electronically. The documentation will
normally be delivered at least two weeks prior to the visit.
c) Documentation to be forwarded to you will include the application documents submitted by the
institution, a set of the CAA Standards (also available on-line in the Commission’s website
http://www.caa.ae), and, where appropriate, examples of reports to give some idea of the level of
detail required.
d) A template for the report will be provided by the Commissioner and distributed to the ERT
members in advance of the arrival in the UAE.
e) ERT members must be sure to bring all documents for the visit in electronic form. Hard copy is
provided by the institution onsite.
Pre-Visit Preparation
a) The ERT Chair, in consultation with the Commissioner, will coordinate the partitioning of
responsibility across ERT members for document reviewing and report writing. This usually
include email communications and other exchanges of information prior to the visit. It is very
important for team members to participate in these activities as they are an important contributor
of the overall success of the visit.
b) Advance preparation for a visit is essential. Time is limited during the visit, and the more writing
and preparation that can be done in advance, the better. It is often the case that substantial sections
of the report can be written on the basis of documentation sent in advance. The onsite visit
becomes an affirmation (or not) of the previously written materials. If you identify missing
information or additional documentation that is necessary, or wish to propose additional meetings
in the schedule, you should discuss this with the Commissioner in advance of the onsite visit.
c) It is expected that ERT members will familiarize themselves with the CAA Standards and the
documentation provided by the institution in relation to those sections assigned by the Chair. It is
good practice to share preliminary drafts with the Chair and with the Commissioner prior to your
arrival.
d) It is an expectation that ERT members will identify major issues within their areas of responsibility
and will present these on the first meeting of the ERT onsite.
Orientation and General Information
a) There will be an onsite orientation (day 1 on campus) for both new and returning members of
ERTs. In some instances, the orientation will be on the day of arrival; in most instances the
orientation will be held in conjunction with Preparation Day.
b) During the preparation day, the Commissioner will respond to any questions, clarify details about
the itinerary and report, provide a brief overview of the local culture and higher education context,
and give background information on the institution. While most ERT members have extensive
experience of accreditation in their home countries, in the UAE the Standards are used to judge
the quality of the documents presented and respond to the onsite observations.
c) Meetings on the preparation day will sometimes be held in the hotel; more often the preparation
day is on the campus, and typically includes a general orientation to the visit. There are times
when the institution will want to formally greet the ERT at the beginning of the preparation day.
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d) Be certain to check your itinerary or schedule to confirm departure times on the first morning of
the campus visit. Teams operate on a tight schedule and you should make every effort to be a few
minutes early for departure from the hotel.
e) On accepting the role of serving as a member of an ERT, all matters pertaining to the institution,
the deliberations during the review and the contents of the report must be considered as
confidential. Any conflicts of interest should be declared to the Commission in advance of the
visit, immediately, as they become evident to the ERT member
f) ERT members are encouraged to bring their own laptops. If you are unable to bring your own
laptop, please notify the Commissioner in advance so that arrangements can be made to have a
computer at your disposal during the visit.
g) The Commission does not provide secretarial support to the ERTs for report writing, and members
are expected to type the report sections themselves.
Visit Process
a) Once onsite at the institution, adherence to the itinerary is the responsibility of the ERT members
and the Commissioner. Due to the limited time on campus and the issues to be covered, every
attempt should be made to adhere to the timings in the itinerary.
b) If an ERT member feels that there should be modifications to the itinerary, the ERT and
Commissioner should discuss the suggested change. If a decision is made to change the itinerary,
implementation of the change is the responsibility of the Commissioner in consultation with the
institution.
c) During the visit, the Commissioner will take an active part in all meetings and other discussions
to ensure that the ERT and the institution are kept informed about the Commission Standards and
the Ministry protocols. It is the Commissioner’s responsibility to ensure that the Standards are
enforced consistently.
d) During the visit, the ERT members are expected to respect the culture and tradition of the UAE.
They are also expected not to base their evaluation solely on systems or practices applied at their
own institution and should refrain from reference to their own institutions. The broad standard for
ERT reviews is that of “best international practice”. There are many Standards which require ERT
members to exercise their reasoned professional judgment.
e) The ERT is expected to produce a final report before departure. It is important that the report
covers all those areas in the Standards of relevance to the review. For example, program reviews
normally involve a thorough and close examination of course syllabi and course files. The
Commissioner will guide the team members on the necessary coverage and the level of detail
required.
f) The Commissioner is with the ERT to support the team, and to assist where necessary to ensure a
complete and comprehensive report, but the report itself is the work of the ERT.
g) The ERT must agree on the final report and specifically the requirements and suggestions prior to
the exit interview and their departure from the UAE.
h) It is extremely important to note that the ERT does not indicate to the institution whether they
would accredit or not accredit the program under consideration and that the report is strictly
confidential.
i) An exit interview is held with the institution’s CEO, academic administrators, and program
coordinator/director, providing the highlights of the report. The institution is not provided with
any hard copy at this stage and the meeting cannot be recorded.
j) At the exit interview, the Commissioner will generally thank the institution for their cooperation,
hospitality, etc. Following the Commissioner, the Chair of the ERT normally will present the
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summary of the key findings of the ERT. The Chair may ask other members of the committee to
cover specific areas of the report. The exit interview does not quote the requirements verbatim.
k) The exit interview is not an opportunity for debate. The institution may ask for points of
clarification but there should be no debate of the issues.
l) All communication between the institution and the ERT is to take place only through the
Commissioner, whether it is prior to the visit or after the visit. No member of the ERT should
engage with the institution on a consultant basis for at least a year following the assignment.
m) At the end of the visit, ERT members who wish to leave behind any of the documents should refer
to the Commissioner to arrange for appropriate disposal of such material.
n) As part of the final activities on campus, ERT members will be required to: (1) Agree to and sign
a form which recommends an action on the part of the Commission; and (2) Complete an
evaluation of the visit which will be left with the Commissioner.
The Report
a) The report must cover all those areas in the Standards of relevance to institutional licensure or
program accreditation. The areas of Standards coverage to be used in the review process are
delineated in the report template. Be sure to use the appropriate Procedural Manual that relates to
the current review. The Commissioner will guide the team members on the necessary coverage
and the level of detail required
b) The report must indicate where the institution/program meets the Standards and where it does not.
Further action on the part of the institution, to fulfill the requirements of the Standards, is made
clear through stated Requirements in the report, based on observations noted in the report and
supported by evidence acquired during the onsite visit.
c) The expertise of team members in the discipline field can be used to make helpful Suggestions in
the report for improvements that can be made to the institution/program. These beneficial
Suggestions can include changes that are outside of the Standards.
d) The narrative of the report can be a place in which the ERT offers constructive advice that falls
short of a suggestion.
e) See Annex 1: Some Guidelines for CAA Accreditation Reports. These guidelines provide
directions for the development of Requirements, and Suggestions.
Follow-Up to the Visit
a) Minor editing of the report will be done by the Commission prior to sending the final report to the
institution. If major editing is considered necessary, the Chair and relevant ERT members will be
consulted. Once the report is finalized, it becomes the property of the CAA and is under the control
of the CAA for distribution. ERT members should not independently send the report or portions
of it to the institution.
b) Upon receiving the report, the institution reviews it and provides a written response to the CAA
explaining how it will meet the Requirements noted by the ERT. The institution must also
document its consideration of the ERT’s Suggestions. The institution is normally requested to
respond to the report within two months of receipt. The institution will respond to the report in
keeping with the Procedural Manuals provided to all institutions.
c) If major changes required to the curriculum or other technical issues are addressed in the response,
it is likely that the Commission will contact the ERT Chair to review the response from the
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institution, for which an additional honorarium will be paid. If the Chair is not available, another
ERT member will be asked to perform this role. It is the judgment of the Commissioner as to
whether the ERT is consulted as part of the review of the response.
d) The assessment of the institution’s response is sent to the institution for a further response. The
response and assessment procedure continues until all the ERT’s Requirements have been met. It
is normal practice to issue a decision of Deny in the event of Requirements not having been met
after three rounds of institutional responses.
e) Once all of the ERT’s Requirements are met, the request for Institutional Licensure or Program
Accreditation is forwarded to the CAA Council of Commissioners for endorsement (or not).
f) Upon approval, the institution is licensed or the program is accredited for up to maximum of seven
years and its status is posted to the CAA website.
Annex 1: Some Guidelines for CAA Accreditation Reports
The report will follow relevant sections from the Standards. The text within each section essentially
follows one of two patterns.
In what follows, “ERT” is shorthand for “External Review Team”. “EITS” is short for the name of
the institution (Emirates Institute of Technology and Science; a UAE higher education institution).
Narrative + Requirement
A Requirement is an obligation on the institution to address a failure to meet the Standards in some
way. Requirements always begin:
“Requirement ##: EITS is required to ...”
Each requirement must be preceded by a narrative which explains and justifies its appearance.
Although the word used is “Requirement”, it is important to note that these are in fact obligations,
and the institution will have to present evidence to the CAA (most usually in its response to the ERT
report) that it is now in compliance with the Standards.
In some cases, the Standards are very prescriptive – so that the facts of the matter make it clear that
the institution is not in compliance. The example below illustrates that pattern.
8.3 Operations
The ERT finds no reference to an orientation program for new users of the library.
Requirement ##: EITS is required to develop an orientation program for new users of the
library in line with Stipulation 8.3.1 of the Standards.
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Sometimes the issues are more complex and several are related. The ERT may try to combine a
family of requirements into a single unit. Here is a more complex example:
6.3 Graduate Admission
EITS has specified the requirements for admission to the proposed program. The application states
that the “minimum requirement is a baccalaureate degree with at least 50% of the credits from a
recognized institution of higher learning in IT or related discipline.” The ERT finds this statement
confusing and needs clarification. During discussions, EITS staff clarified that “related
discipline(s)” are: Computer science, management information systems, computer information
systems, mathematics, physics, and any field of engineering. This clarification creates additional
issues, given the program objectives and structure, as discussed earlier in Section 3.5.1. The ERT
feels strongly that it is in the best interest of EITS to either (a) restrict admission to those who
hold a bachelors degree in IT, Computer Science, or MIS or (b) require completion of a prescribed
set of remedial IT courses for those who do not have any formal education in IT, computer science
or management information systems. EITS staff informed the ERT that “50%” refers to the level
of achievement in the applicant’s undergraduate studies, and roughly translates to a CGPA of 2.0
on a 4.0 scale. This is in clear violation of the Standards.
Requirement ##: EITS is required to:

i. revise its admission standards to increase the level of achievement in the
applicant’s undergraduate corresponding to a CGPA of at least 2.5 on a
4.0 scale, as required by the Stipulation 6.3.4; and
ii. either restrict admission to the MITM program only to those applicants
who have obtained a bachelor’s degree in IT, management information systems or
computer science, or require completion of a prescribed set of remedial IT courses for
those who do not have a formal education in IT.
In some cases it is clear that, while the institution is not in compliance, it is evident that there is
credible progress towards compliance. In such cases, the Commission insists that this progress
continues, sometimes asking for an additional time-phased plan for completion of the task by a
specified date. Here is an example:
8.1 Learning Resource Center Facilities and Infrastructure
A library facility is currently under construction at EITS’s temporary campus. Significant

progress has been made since the accreditation of an earlier program in March 2019. In
particular, the building is expected to be completed by mid-May 2019, the furniture available
by the end of May 2019 and the holdings, computers and automated systems in place by the
beginning of July 2019. EITS is in the process of appointing a Head Librarian and two
assistants in the next few weeks.
The Committee commends EITS for addressing the requirements of the ERT of the previous
accreditation committee so swiftly and has confidence that those requirements will be met.
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Requirement ##: EITS is required to complete the physical and human resourcing for its
library by the beginning of July 2019.
Most often, and particularly in the sections concerning the content or delivery of the curriculum, the
Standards require experts to interpret what is good practice, appropriate, credible, sound, and so on.
In these cases the ERT has more scope, and therefore power, so must bear in mind that it should not
(a) impose its personal preferences, (b) insist on “best” practice (but it must, of course, be “adequate”;
and it can encourage better practice through suggestions, and (c) impose someone else’s formal
standards. It is even more important, in this case, to explain, in the narrative, in what respects the
proposal fails to meet the Standards.
Some examples:
MAT 101: College Algebra
It is not clear that this course provides knowledge and skills which are either necessary for
further study on the program, nor for the kind of employment opportunities of which
successful students will take advantage. In addition, the material will be inaccessible to many
applicants without remedial training. It is, therefore, very important to determine whether or
not this material is relevant for the program. The ERT feels, after discussions during the visit,
that it is not.
Requirement ##: EITS is required to remove course MAT 101 from the curriculum.
Another:
ICT 251: Database Management and Design
After detailed discussion during the visit, the ERT was persuaded that:
 his is a central topic of the program and is currently placed too late in the program;
it is needed as a pre-requisite, for example, for ICT 291.
 If the course is concerned with the design of databases, then material on
normalization, which is currently missing, must be added.
 If the course is about relational databases, then material on object-orientation is
probably irrelevant and can be removed.
Requirement ##: EITS is required to:

i. revise the Learning Outcomes, Syllabus and Assessment Schedules for
course ICT 251 to include material on database normalization; and
ii. move course ICT 251 from the fourth to the third semester.
Another:
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The ERT did not understand why ITCS 303 is a prerequisite for ITCS 307, nor why the
prerequisite for ITCS 401 is ITCS 303 (in the Application), ITCS 302 (in the University
Catalog) and yet another course (in a paper tabled during the onsite meetings). The ERT did
not understand why ITCS 402 has two prerequisites, one of which is already a prerequisite of
the other.
This suggests that the whole issue of prerequisites should be revisited.
Requirement ##: EITS is required to revise the course prerequisites for the Computer
Science courses proposed for the Program.
Narrative + Suggestion
Sometimes the ERT may have good ideas, or advice on best practice for the institution which it
cannot impose because the issue or advice does not involve a failure to meet the Standards. This
leads to “Suggestions”.
A Suggestion is advice given by the ERT to the institution. It takes the format:
“Suggestion ##: The ERT suggests that EITS ...”
The institution is obliged to consider the Suggestion in its response but is not obliged to implement
it. Normally, unless it is self-explanatory, a Suggestion is also preceded by a narrative.
Here is an example:
ISL 201: Islamic Studies
The ERT engaged in an interesting discussion concerning this course, in particular the
possibility of its being taught (additionally or instead) in English. The ERT learned that there
may well be students on the program whose first language may not be Arabic and whose
cultural background may be varied. In order to promote values of understanding and tolerance
(many of the values, in fact, which are promoted by the course itself) the accessibility of the
material to those with a non- Islamic background would be highly desirable.
Suggestion ##: The ERT suggests that EITS consider giving the course ISL 201 in
English, in addition to Arabic, in order to ensure that the values it promotes are accessible
to all students.
Another:
2. Quality Assurance
The College has developed a Vision and a Mission, which are focused and appropriate.
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The ERT fully approves of the emphasis on active learning but feels that the explicit contrast
with traditional teaching is unnecessary in this context.
Suggestion ##: The ERT suggests that EITS delete “... rather than traditional teaching ...”
from the Mission Statement.
Finally:
Although the Program Learning Outcomes are felt to be appropriate, the College may wish to
consider expanding them and organizing them according to type (possibly into groups of
knowledge, cognitive, practical and transferable skills), as has been done for the Bachelor of
Business Administration in Information Systems program. This suggestion is partly motivated
by the presentation given to the ERT during the visit, when systems analysis and design,
distributed systems and information management tools were identified as key foci of the
program. These are not reflected currently in the Program Learning Outcomes.
Suggestion ##: The ERT suggests that EITS consider revising its Program Learning
Outcomes and to group them by type into Knowledge, Cognitive, Practical and
Transferable skills.
Narrative + Commendation
In rare instances, the ERT will want to recognize an institution for a practice or a curricular element
which is truly an example of “best practice.” The CAA recognizes the use of a “Commendation” in
those instances although such commendations should not be given lightly.
An example:
3.3 Program Structure and Completion Requirements
After a thorough review of the curricula of the program in biology and after a review of the
laboratories associated with that curriculum, the ERT commends EITS for the integration of
the laboratories with the larger curriculum and the degree to which there is a close articulation
between the learning outcomes of the laboratory instruction and the overall program goals.
The ERT commends this integration as an exceptional example of international best practice.
Another example:
3.8 Internship or Practicum
The ERT was most impressed by the clarity of the Internship Handbook which is applicable
to the program in biology. What is most impressive is the follow through to ensure that the
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site supervisors have worked closely with faculty coordinators to ensure that the internship
meets the learning outcomes and that there is appropriate documentation that all learning
outcomes are met. The ERT commends the thoroughness of the EITS internship program as
an example of international best practice.
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APPENDIX 12: PROCEDURES
Conflict of Interest for ERT
The purpose of the attached “Conflict of Interest Disclosure Statement” is to maintain the integrity,
credibility, and codes of good conduct in accreditation and policy making processes and to avoid
actual conflicts, potential conflicts, or even the appearance of conflicts of interest in the Commission’s
decisions. Individuals covered by this policy may serve in the capacity of Commissioner,
Commissioner Pro Tempore, Team Chair, Team Member, Substantive Change Committee Member,
Periodic Review Report Reviewer, Candidate Consultant, and/or Finance Associate.
The Commission relies on the personal and professional integrity of individuals to refuse any
assignment where the potential for an actual or perceived conflict of interest exists. The Commission
expects any committee member, team chair, evaluator, PRR reviewer, or other individual acting on
behalf of the Commission to recuse him or herself from any discussion or accreditation decision if
any of the following conditions exist. The Commission will not assign an individual as a chair, team
member, reader, or reviewer if:
 the individual’s home institution is part of the same system;

 the individual has been a candidate for employment in the evaluated institution within the past
year;
 the individual has been employed by the institution within the past five years;
 the individual belongs to the governing body of the institution;
 the individual has a personal, business, consultative, or other interest in or relationship to the
institution under review and consideration that could affect his or her objectivity;
 the individual’s institution has a material interest in a positive accreditation outcome based on
a significant business or other fiduciary agreement (excluding routine articulation or similar
inter-institutional agreements);
 the individual has a family member who is an employee, board member, candidate for
employment, or student at the institution;
 the individual has expressed personal opinions bearing upon the accreditability of the
institution;
 the individual is an alumnus or alumna of the institution;
 the individual or his or her immediate family members hold shares of stock (excluding shares
held indirectly through mutual funds, insurance policies or blind trusts) in an applicant,
candidate or accredited institution, or their respective parent company or affiliated entity. An
“immediate family member” would ordinarily include all persons in the same household, such
as a roommate, spouse, minor child, or other dependent; or
 in the individual’s judgment, there is any other circumstance that could be perceived as a
conflict of interest.
In addition, Chairs, team members, PRR readers, substantive change committee members, finance
reviewers and others usually may not serve in any capacity if the individual’s home institution is in
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the same state in which the institution being reviewed is located.
In some cases, exceptions may be made to these policies after consultation with the institution to be
visited.
Consulting by Evaluators/Commissioners
To avoid the appearance of possible conflict of interest, no member of a visiting team may serve as a
paid consultant in any area related to accreditation to the institution being visited for a period of one
year following the official accrediting action. The institution is expected to respect the process by not
engaging any team member as a consultant for one year following evaluation or considering any team
member for permanent employment within one year of the evaluation.
Commissioners may not receive consulting fees or any other form of remuneration for any
accreditation-related consulting from any Commission member or candidate institution.
Seminars or workshops for faculty or administrators to share institutional or discipline-related

information or expertise are not considered to be accreditation-related.
Conflict of Interest Disclosure Statement
In accord with the Commission’s policy statement, “Conflict of Interest,” please read carefully the
disclosure statement below and, to the best of your judgment, disclose any conflicts or potential
conflicts of interest at the bottom, and sign and return the form to the Commission office as soon as
possible. The Commission will use the information provided to help control the compilation and
distribution of information for participants in the accreditation process, to monitor the participation
of readers and representatives on visits, and to determine who participates in discussions or decisions
concerning institutions. If, in your opinion, you are not involved in any situations or circumstances
which would be considered conflicts or potential conflicts of interest, simply write “None” on the
form.
Rationale
relationship between the Commission and each of its licensed institutions. It is a relationship in which
all parties agree to deal honestly and openly with their constituencies and with one another. Without
this commitment, no relationship can exist or be sustained between the Commission and its licensed
institutions or other institutions in the UAE. Commissioners, Commission staff, External Review
Team (ERT) members, consultants, or others associated with the Commission are expected to make
a conscientious application of the Standards for Institutional Licensure and Program Accreditation
(2019). The Commission’s requirements, policies, processes, procedures, and decisions are predicated
on integrity.
process that requires international experts to review institutions and programs and to make
recommendations about their licensure or accreditation. In order to maintain the credibility of those
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decisions, not only must the Commission hold institutions accountable for integrity governing all
aspects of their operations, but it also must ensure that reviewers responsible for making
Confidentiality
All External Review Team (ERT) members and consultants, or others working with the Commission,
must maintain complete confidentiality and conduct themselves with professional integrity in all
licensing and accreditation activities and decisions. Confidentiality applies to all levels of the review
process. Confidentiality applies to all documents, correspondence, and discussions relative to all
phases of a review.
Unless the disclosure of such information is appropriate as a part of the Commission’s work with a
specific institution, ERT members, consultants, or others working with the Commission may not
disclose to any person or persons other than Commissioners and Commission staff the following:
1. information about an institution or an institution’s program scheduled for review, including the
analysis of institutional materials; information gained from meetings; committee discussions
before and during the review; and the resource material;
2. information distributed as part of Commission staff memos and oral comments by staff ;
3. decisions of the ERT or the Commission; or
4. the rationale for a decision of the Commission pertaining to an institution.
Without a commitment to confidentiality by ERT members, consultants, or others working with the
Commission, in all aspects of the review process, they will not be able to freely execute their
responsibility to conduct themselves with professional integrity in accreditation or licensing activities
and decisions.
The Commission for Academic Accreditation seeks to ensure that the personal or professional
obligations or interests of ERT members, consultants, or others working with the Commission do not
interfere with their ability to conduct their duties in a fair and impartial manner. This policy statement
defines those areas that the Commission considers to represent an actual or potential conflict of
interest. The Commission’s purpose in defining these parameters is to:
a. maintain credibility in the licensure and accreditation process and confidence in its decisions;
b. assure fairness and impartiality in decision-making;
c. avoid allegations of undue influence in the licensure and accreditation process; or relationships
that might bias the actions, deliberations, or decisions of the Commission; conflicts that would
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impair judgment; and circumstances that could interfere with an individual’s capacity to make
objective, detached decisions; and
d. assure opinions free of self-interest and personal bias.
If an ERT member or consultant is a candidate for a position with an institution, he or she must
immediately notify the Commission and must not be involved in any Commission activity related to
that institution.
Any professional consulting arrangement or other employment arrangements between ERT members
or consultants and institutions may be made only with the approval of the Director of the Commission.
In addition, the Commission relies on the personal and professional integrity of individuals to refuse
any assignment in which an actual or potential conflict of interest exists. If an unanticipated actual
conflict of interest develops, the ERT member or consultant should withdraw at that point.
In all cases, it is the responsibility of the ERT member, consultant, or other person associated with the
Commission, to determine whether or not an outside relationship does in fact constitute a conflict of
interest.
This policy was based on the Middle States Commission for Higher Education Conflict of Interest for
Employees and the Commission on Colleges of the Southern Association of Schools and Colleges
Ethical Obligations of Commissioners statements: 7/7/2009.
Conflict of Interest Statement for ERTs and Consultants

I hereby certify that I have read the policy statement of the Commission for Academic Accreditation
regarding Ethical Obligations of External Review Team Members and Consultants. I further certify
that I have no conflict of interest or potential conflict of interest related to my engagement with the
Commission or related to any of the institutions licensed by or under the aegis of the Commission that
would prevent me from providing a fair, impartial and unbiased opinion in connection with my work.
In the event any conflict of interest or potential conflict of interest may arise during the course of my
engagement with the Commission, I will promptly notify the Director of the Commission and will
dissociate myself from any Commission work related to that institution.
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APPENDIX 13: ENTITLEMENTS OF ERTS
a) Airplane flights/transport
 Round-trip, business class return air tickets between the airport of origin and the United Arab
Emirates.
o Travel itineraries may begin in one city and end in another, if so requested by the ERT
member
o Arrival and departure dates in the UAE are flexible if so requested by the ERT member.
Additional costs (hotel nights, etc.) associated with an early arrival or a late departure
are at the reviewer’s expense.
 Reimbursement for expenses of ground travel between an ERT member’s home and the airport
of origin, on presentation of receipts. This would include taxi costs or airport parking fees.
 Round-trip transport between the UAE airport of arrival/departure and the hotel used by the
ERT.
 Transport for ERT members between the hotel and the campus of the higher education
institution (HEI) being reviewed is normally provided by the HEI.
b) Hotel accommodation
 Accommodation in a five-star hotel convenient to the HEI being reviewed, with all taxes and
tourism fees paid.
 A daily allowance for meal expenses usable at any restaurant in the hotel, for room service or
for minibar snacks (excepting alcoholic beverages).
 An allowance, covering the entire visit, for laundry services that are charged to the hotel.
c) Honorarium payment
 An honorarium payment of AED 2000 per working day of the review visit, plus one additional
day’s honorarium covering travel and preparation.
 A Chair of an ERT is entitled to one additional day’s honorarium.
After its approval by the Minister, the provisions of this policy are binding on MoE staff responsible
for air ticket bookings and other logistics arrangements.
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APPENDIX 14: ERT REPORT TEMPLATE
Cover Page
Notice
Institutional Licensure and Program Accreditation, 20191[hereinafter referred to as the Standards],
and the Procedural Manual for Initial/Renewal of Institutional Licensure [PMIIL/PMRIL]. This
report is for internal use only and is not for release except as allowed by policies of the Commission
for Academic Accreditation.
Introduction
[Note to ERT: The introduction will be expanded “on site” and tied to the specific institution. I will
plan on drafting this on behalf of the ERT]
xx, to evaluate the Application (hereafter the Self-Study/Application) for Initial/Renewal of Licensure
of the (the institution name). The exit interview was held on (date). This report presents the
observations and recommendations of the ERT.
…..
…..
visit, oral presentations, and information resulting from in-depth discussions. The report also includes
Requirements, which are actions (the institution acronym) must take in order for the institution to
receive Licensure, as well as Suggestions that, although not binding, must be considered by (the
institution acronym).
Institution Report
[Note for ERT: There are aspects of the Standards which are more applicable to Licensure or the
Renewal of Licensure (both of which consider the entire institution) than to Initial Accreditation or
of Renewal of Accreditation. That has meant that in the template below, I have eliminated some of
the sections as not needing your attention during this visit. For initial licensure we are looking at
promises; for renewal of licensure we are looking at results.
Some division of labor seems appropriate for the review. What has worked in the past is to assign
the broad institutional sections (support areas) to one of you and divide the institution areas by
specific expertise. If each of you will write on the designated sections, and give particular attention
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to those, the report should come together nicely. As a Chair, (Name of the Chair) will have
responsibility for bringing the narratives together (including what I will do on the introduction; I
will be happy to assist on all of this if it will help).
Word document. As a first stage, you are writing (the more done ahead of time the better) some and
raising questions which will need to be answered on site. Later stages of writing allow you to polish
and then it is a “cut and paste” task from there. Given that, this is an institution in which each of you
has expertise in it, some division of labor seemed appropriate. I’d ask (Name of the Chair), as a
Chair, to review the assignments and determine whether or not any changes are appropriate. The
design of the assignments is to focus your attention on particular areas and facilitate the writing
process.
As to using the template, there is no need to worry about the extras at this point. There is no need,
for example, to bold face certain sections italicize, etc. If you are quoting a text, obviously put it in
quotation marks and give a citation. I will work through the document during the editing phases to
insert bold face, italics, underlines, bullets, etc. where they are needed.
(Name of the Chair), as a Chair, may want to make changes in assignments, just let me know.
section as noted.
As a committee goal, we should plan on having our report fully merged by late afternoon on Day 3
so that we can spend the morning of Day 4 (Last Day) fine tuning, going over what it is that we
want to say at the exit meeting, completing required CAA forms, etc. If you are able to get the
initial merged document to me by the third day, I can begin the editorial process and begin
attempting to make the document sound like “one voice.” Some of that occurs in the initial edit;
most will take place after you return to your respective homes and after I get back to the office.
From the draft schedule/itinerary for the visit, you will know that we will be busy; the more writing
that you can do in advance of your arrival (writing that would be based on the documents which
already sent to you), the better.
• Your narrative is a statement of compliance and/or noncompliance with the issue. Include a
statement of the evidence for your conclusion (i.e. interviews, the Application, Self-Study, one or
more of the appendices, international norms, etc.)
For examples and ideas on writing the narrative, please consult the Handbook for
documents.
The “Standards” for compliance and/or noncompliance are those outlined on pages 18-23 of the
Standards for Institutional Licensure and Program Accreditation, 2019. The document is
available on the CAA website. Be sure to use the appropriate procedural manual, for initial
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licensure use the Procedural Manual for Institutional Initial Licensure (PMIIL) and for Renewal
of Licensure use the Procedural Manual for Renewal of Institutional Licensure (PMRIL) which
are also available on the CAA website.
• On the template I’ve listed the broad headings from the Standards to organize your writing.
Your analysis and judgment should be inclusive of all subsections of the Standards as
appropriate to the institution.
• Although you may offer constructive commentary on each area of the template, you must
offer a summary of the documentation reviewed and the context for all requirements and
suggestions.
• Your comments may be inserted on the template and then conveyed to the Chair of the
ERT during the visit as requested.
Standard 1: Governance and Management
1.1 Vision and Mission

1.2 Organization
1.3 Governance
1.4 Policies and Procedures
1.5 Institutional Planning
1.6 Risk Management
1.7 Institutional Management and Administration
1.8 Multiple Campus Institutions within the UAE
1.9 Campuses of UAE Institutions in Other Countries
1.10 Branch Campuses of Foreign Institutions
Standard 2: Quality Assurance

Standard 4: Research and Scholarly Activities

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Standard 7: Health, Safety and Environment
7.1 Occupational Health and Safety

7.2 Facilities
7.3 Residence Halls
7.4 Technology Infrastructure
Standard 9: Fiscal Resources, Financial Management and Budgeting
9.1 Fiscal Resources

9.2 Student Protection Plan/Teach-out Reserve
9.3 Organization and Administration
9.4 Budgeting
9.5 Expenditures
9.6 Financial Management
9.7 Accounting and Auditing
9.8 Financial Reporting to the MoE
9.9 Insurance
Standard 10: Legal Compliance and Public Disclosure
10.1 Institution Name and Program Titles

10.2 Legal Compliance and Contracts
10.3 Public Information
10.4 Integrity and Transparency
10.5 Relationship with the MoE
Standard 11: Community Engagement
11.1 Community Engagement Strategy

11.2 Relationships with Employers
11.3 Relationships with other Education Providers
11.4 Relationships with Alumni
11.5 Continuous Education
11.6 Evaluation
Conclusions
[Note to ERT: This will be a summary statement written by the Chair of the ERT. It is often the case
that the initial draft of the conclusion is the written text for the remarks to be made at the exit meeting.
It should generally point toward whether or not you are recommending approval of licensure, approval
only if the requirements are met, or disapproval of licensure. You should not, however, actually make
a requirement in the conclusion.]
[Note to ERT: This statement is boilerplate and is the last section of every concluding statement:]
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the Standards are met, and to aid the (the institution acronym) in its desired objective to license the
institution.
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APPENDIX 15: AGENDA TEMPLATE
Cover Page
Day 0: Arrival Day
No ERT activities planned.
Day 1: Preparation Day
9:00 AM – 11:00 AM Preparation meeting for ERT at the campus
This day will be preparation, including orientation, review of

documents, and writing. All appropriate institutional and
program documentation should be available.
Note to institution Staff: The base room on the campus should

include internet access and a computer workstation with printer
capability. Should also include the institutional documentation
on this program including course files (including textbooks)
for all courses offered in the program (including general
education, electives, and any courses offered by other
departments/colleges), the Self-Study, Faculty Handbook, Staff
Handbook, Student Handbook, Catalog, Quality Assurance
Manual, Policies and Procedures Manual, Fact Book, Strategic
and Action Plan(s) – institution level, Strategic and Action
Plan – college/department level, Organizational Chart (with
names of current appointees and vacant positions) for both
institution and college/department level, assessment reports,
assessment information, course schedule for the last two
semesters, current study plan for the program and related
programs, faculty roster for full-time and part-time for the
college/department categorized by program (detailing name,
rank, highest degree earned, specialty, joining date), detailed
faculty working/teaching assignment for the
college/department categorized by program (specified courses,
number of sections, credit hours, admin responsibilities, and
total load) for the last two semesters, list of faculty
publications in the program for the past two academic years,
actual expenditures on research for the program in the past two
academic years, complete faculty files, complete staff files
(who are related to the program), list of books and current
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journals (related to the program), list of current students in the
program (detailing name, student number, admission date,
TOEFL score, TOEFL score date, number of credits enrolled,
number of credits passed, and GPA), institutional student
population for the current academic year categorized by
program/college, student appeals for the last two semesters,
minutes of college/department committees, advisory board,
etc. All required documents should be available in the base
room.
Provision for coffee, tea, and light snacks is appreciated

throughout the visit.
11:00 AM - 11:30 AM ERT meets with the President
Note to institution: This is an introductory meeting; the

ERT expects a brief presentation about the institution.
11:30 AM - 1:00 PM ERT interviews with the Chair of the program and Dean
of the college.
Note to institution: The specific of the presentations by

the Chair and/or Dean are the responsibility of the
institution. Given that this will be a tight schedule, the
team urges the institution to keep overview
presentations brief. The majority of the time should be
for discussions and question. The institution shall
decide on the personnel to be in the meeting.
1:00 PM ERT working lunch; no campus personnel
2:00 PM - 4:00 PM Continue preparation meeting for ERT
Day 2: Campus Workday
9:00 AM - 12:00 PM Executive session for ERT
12:00 PM - 1:00 PM Tour of campus facilities that are relevant to the

program
Note to institution: This tour should include the library,

laboratory facilities, and other facilities associated with the
160
program. Need not to be a comprehensive tour of the whole
campus.
1:00 PM - 2:00 PM ERT lunch with representative faculty/staff
Note to institution: This lunch is designed as, in part, a

social event and, in part, as an opportunity for the ERT
to interact with individuals whom they might not
otherwise have the chance to interview but have an
important role for the program.
2:00 PM - 4:00 PM ERT interviews faculty
Note to institution: This interview time is for faculty

interviews. Also, provide faculty files and a list of
current faculty in the department/college along with
their credentials and teaching/administrative loads. The
ERT will conduct interviews in parallel.
Day 3: Campus Workday
9:15 AM - 10:30 AM Executive session for ERT
10:30 AM - 12:00 PM ERT interviews admin staff
Note to institution: This interview time is for staff

interviews. The ERT will need interview time with: (1)
Head of Quality Assurance; (2) Head of Student
Services; (3) Head of Research; (4) Head of IT
Services;
(5) Head of Library; (6) Head of Finance; (7) Head of

Human Resource; and (8) Head of Admission and
Registration.
The ERT will conduct interviews in parallel. This might

also include follow-up interviews as requested through
the Commissioner.
12:00 PM - 1:00 PM Executive session for ERT
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2:00 PM - 4:00 PM Students, alumni, Advisory Board, and employers

interviews
Note to institution: These are particularly important sessions

for an accreditation visit. The institution should arrange for a
representative sample of students and alumni of the program
(one session) and members of the external advisory board and
employers of the program (a second session). Sessions should
be no more than 45 minutes.
4:00 PM ERT leaves for hotel
Day 4: Exit Day
9:00 AM -12:30 PM Working executive session for ERT
1:30 PM - 2:00 PM Exit meeting
Note to institution: This meeting includes President, Dean,

Chair, and others as invited by the institution.
This exit meeting will be an overview of the findings of the

ERT; there will not be time for discussion other than for
purposes of clarification. During this exit meeting, the
Commissioner will present an overview of “next steps” for the
institution as part of the accreditation process.
The format for the meeting will begin with opening remarks by
the Commissioner, the presentation by the ERT Chair and a
brief closing by the Commissioner. The President may wish to
make very brief final remarks, but the exit meeting is not the
time for questions or begins responding to the report. The
institution shall decide on the personnel to be in the meeting.
2:00 PM ERT departs for hotel
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APPENDIX 16: ETHICAL OBLIGATIONS OF COMMISSIONERS AND
COMMISSION STAFF
Rationale
relationship between the Commission and each of its licensed and candidate institutions. It is a
relationship in which all parties agree to deal honestly and openly with their constituencies and with
one another. Without this commitment, no relationship can exist or be sustained between the
Commission and its licensed and candidate institutions. The Commission relies on Commissioners,
Commission Staff, Consultants, or others associated with the Commission to make a conscientious
application of the Standards for Institutional Licensure and Program Accreditation. The
Commission’s requirements, policies, processes, procedures, and decisions are predicated on
integrity.
process that requires institutional representatives from all degree levels to review institutions and to
make recommendations about their licensure or accreditation status. In order to maintain the
credibility of those decisions, not only must the Commission hold institutions accountable for integrity
governing all aspects of their operations, but also must insure that reviewers responsible for making
Obligations of Commissioners, Commission staff, consultants, or others working with the

Commission
Reviewers have an obligation to represent all recommendations as those of the total committee and
not those of particular individuals or groups. When making this collective decision, it is paramount
that reviewers provide for each other an environment that supports a candid exchange of ideas, an
opportunity for all opinions to be considered, a respect for individual differences and honest dissent,
and a commitment to hold in confidence all such exchanges.
Confidentiality
All Commissioners, Commission Staff, Consultants, or others working with the Commission must
maintain complete confidentiality and conduct themselves with professional integrity in all licensing
and accreditation activities and decisions. Confidentiality applies to all levels of the review process.
Confidentiality applies to all documents, correspondence, and discussions relative to all phases of a
review. Commissioners, Commission Staff, Consultants, or others working with the Commission are
expected to maintain confidentiality regarding input from Reviewers, Commissioners and
Commission Staff just as they do regarding all other discussions conducted during the review process.
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As examples, Commissioners, Commission Staff, Consultants, or others working with the
Commission may not disclose to any person or persons other than Commissioners and Commission
Staff the following:
1. information about an institution or an institution’s program scheduled for review, including

the analysis of institutional materials; information gained from meetings; committee
discussions before and during the review; and the resource material;
2. information distributed as part of Commission Staff memos and oral comments by staff;
3. decisions of the External Review Team or the Commission; or
4. the rationale for a decision of the Commission pertaining to an institution
Without a commitment to confidentiality by all Commissioners, Commission Staff, Consultants, or

others working with the Commission and in all aspects of the review process, they will not be able to
freely execute their responsibility to conduct themselves with professional integrity in accreditation
or licensing activities and decisions.
The CAA seeks to ensure that the personal or professional obligations or interests of all Commissioners,
Commission Staff, Consultants, or others working with the Commission do not interfere with their ability
to conduct their duties in a fair and impartial manner. This policy statement defines those areas that
the Commission considers to represent an actual or potential conflict of interest. The Commission’s
purpose in defining these parameters is to:
1. maintain credibility in the accreditation process and confidence in its decisions;

2. assure fairness and impartiality in decision-making;
3. avoid allegations of undue influence in the accreditation process; relationships that might bias
the actions, deliberations, or decisions of the Commission; conflicts that would impair
judgment; and circumstances that could interfere with an individual’s capacity to make
objective, detached decisions; and
4. assure opinions free of self-interest and personal bias.
Commissioners, Commission Staff, Consultants, or others working with the Commission will not be
assigned to work with an institution at which they have previously been employed. If an employee is
a candidate for a position with an institution for which he or she is the designated liaison, the employee
must immediately notify the Director and relinquish responsibility for that institution to another
employee. No employee may serve as a liaison to an institution at which he or she has been a candidate
for employment.
Any professional consulting arrangement, private consulting, or other employment arrangements

between employees and outside organizations or institutions may be made only with the approval of
the Director of the Commission. Employees may not serve as consultants to member or candidate
institutions.
In addition, the Commission relies on the personal and professional integrity of individuals to refuse
164
any assignment in which an actual or potential conflict of interest exists. If an unanticipated actual
conflict of interest develops, the Commissioner or Commission employee should withdraw at that
point.
It is the responsibility of the Commissioner, Commission Staff, Consultants, or others associated with
the Commission in all cases to determine whether or not an outside relationship does in fact constitute
a conflict of interest.
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APPENDIX 17: DOCUMENT CONTROL, MANAGEMENT, CONFIDENTIALITY
AND DISPOSITION
CAA Records Management Policy
Principles
1. Records created or received by staff in the process of conducting CAA business are vital assets
of the CAA, providing evidence of its current practice (decisions, actions, reporting, setting
certain quality standards, business activities and transactions) and for future research while
fully adhering to and complying with the program accreditation and institution licensure
Standards. They support CAA daily functions and operations.
2. The CAA primary technologies used for recordkeeping are the:
 CORE, the electronic archiving system
 CAA website
 CAA portal
 Excel database
 Email
3. This policy applies to records in all formats (paper and digital) whether registered files,
working papers, electronic documents, emails, online transactions, data held in databases or
on USB, maps, plans, photographs, sound and video recordings.
4. This CAA policy and its within described practice are based on its legislative responsibilities.
5. All areas of CAA operations must keep records in accordance with this policy on matters such
as documentation, processing HEIs applications, and any other administrative operations.
Creation and Maintenance of Records
1. The CAA ensures that full, detailed and accurate records are created and maintained to
document its business and activities, including outsourced, contracted or cloud-based
activities, and are captured in recordkeeping systems/technologies to:
 Reinforce efficient and effective operations.
 Ensure business continuity: so that staff undertaking CAA business can access past
decisions, communications and activities. Records must be organized and managed to
maintain their context and ease of retrieval. The records and information to meet both long
and short term needs. They are ready for re-use, and remain accessible for as long as
needed.
 Protect rights: the CAA own legal, financial and other rights and its obligations to Ministry
of Education, Higher Education Institutions and their students, its staff, and others affected
by its actions.
 Support accountability, regulatory compliance and management of risk. Governance
mechanisms ensure that records management practices support appropriate decision
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making and promote accountability and transparency to achieve desired business
outcomes.
2. Records must accurately reflect the activities they document and include sufficient contextual
information or metadata for them to be meaningful, such as the identity of staff who are
undertaking CAA business on its behalf, the date the business is undertaken, source of
information and a description of data provided in statistical and analytical reports and tracking
HEIs applications processing and status. Records provide evidence of what was said and done,
purpose, where, when, and by whom in the conduct of the CAA work.
3. Records should be captured into a recordkeeping system as soon as possible after creation so
that evidence is readily available, valid up to date and in consistence across all recordkeeping
systems and database to support CAA business.
4. CAA records created or received by email or electronic documents held on personal computers
must be incorporated into a recordkeeping system and shared files.
5. Oral decisions, actions, agreements and commitments should be recorded and incorporated
into a recordkeeping system, e.g. documented in a ‘note for file’ incorporated into the relevant
file. Formal meetings should be documented by an agenda, minutes and any supporting
documentation and meeting material.
6. The CAA uses a subject classification structure to classify records in the CORE, the Electronic
Archiving System so that information can be easily located.
7. Records are made available in accordance with the constraints of security, confidentiality, and
archival access conditions
8. A future recordkeeping system must be assessed for compliance with records standards and
functions and operations carried out while processing Higher Education Institutions
applications, before it is implemented or before records are migrated to or from the system. A
major change to an existing system must also be assessed for such compliance.
9. CAA monitors and reviews its recordkeeping for enhancements on regular basis.
10. CAA staff understand and appreciate the value of information as an asset for the Commission
and the Ministry of Education.
11. CAA staff and External Reviewers have an obligation to make and keep full and accurate
records of their activities at all times. The CAA provides an induction process and ongoing
refresher sessions to ensure all staff are aware of the requirements and how to meet them.
Access to Records
1. The CAA provides access to its records to staff that are authorized by the appropriate
delegates. Access may be restricted to particular staff positions or responsibilities or business
areas as deemed required for a particular reason.
2. The CAA’s records must not be provided to a third party without following the appropriate
guidelines in consultation with CAA Senior Management.
167
Record Titling Guideline
1. For records to be accessible and retrievable, and to support CAA decision-making, they should
have a title that accurately describes the content.
2. An accurate and meaningful title is essential at all records levels (whether a file, a folder or an
individual document) as it supports better recordkeeping, reduces duplication and improves
relevance of search results and identification of right information.
3. A record title may be free-text and or follow a set of defined terms as part of a Classification
Scheme. It may include:
 Dates or date ranges: YYYY-MM-DD

 Codes of Higher Education Institutions: UAEU, ZU, HCT
 Type of document: Agenda, Response, Assessment Report, ERT Report, etc.
 Type of Application code: Initial Program Accreditation (IPA), Initial Institutional
Licensure (IIL), Renewal of Program Accreditation (RPA), Renewal of Institutional
Licensure (RIL),
 A version number
 Title elements to be separated with a space
 Keywords for Business Classification
168
APPENDIX 18: DESCRIPTION OF THE CORE
The CORE is a database used by the Commission for Academic Accreditation for a variety of
purposes including the ones listed below:
1. Date of Decree of Institutions

2. List of Licensed Institutions within the UAE with date of initial licensure and expiration,
renewal of licensure dates, due dates for next renewal of licensure.
3. List of accredited programs, type of program, language of instruction, initial accreditation
date, renewal of accreditation dates and due dates for next renewal of licensure and program
accreditations.
4. Searchable list of all members of previous ERTs since 2010, including qualifications,
specialties, contact details, passport information, visit dates and comments from
Commissioners.
5. Schedule of all previous and currently planned site visits listing Institution, program(s), dates
of site visit, Commissioner assigned, and members of the ERT.
6. Applications, Self-Studies and Substantive Changes that have been submitted to the CAA for
review, ERT report, Institution response to reports and ERT review of institutions responses.
7. All documentation related to the final outcome of site visits in response to Applications, Self-
Studies and Substantive Changes.
8. Mechanism to search for reviewers with needed qualifications (specialty areas) for review of
Applications, Self-Studies and Substantive Changes.
9. Completed Quality Assessment forms, Conflict of Interest forms and other forms associated
with CAA reviews.
10. Service providers for CAA
11. Conference data
12. Other information archived, used or collected by the CAA.
169
APPENDIX 19: PUBLIC INFORMATION AVAILABLE ON THE CAA WEBPAGE
The Website of the Commission for Academic Accreditation can be found at www.caa.ae. The
following information is publicly available on the website:
1. Mission, Goals (4), Core Values, and Guiding Principles of the CAA
2. List of Licensed Institutions, accredited programs, and accredited programs given in Arabic
3. Personnel information for the Director, Commissioners, and Staff
4. List of Activities (workshops, information sharing events, etc.)
5. Documents including:
a. Standards for Institutional Licensure and Program Accreditation 2019
b. Supplementary Guidance to the Standards 2019
c. Procedural Manual for Initial Institutional Licensure 2019
d. Procedural Manual for Renewal of Institutional Licensure 2019
e. Procedural Manual for Initial Program Accreditation 2019
f. Procedural Manual for Renewal Program Accreditation 2019
g. Extracts from QFEmirates: A Guide for External Review Teams 2019
h. Guide to Writing Learning Outcomes 2019
i. Guide for External Review Teams 2019
6. License Process and Timeline: Overview
7. Accreditation Process and Timeline: Overview
8. Frequently Asked Questions
9. Enquiries including address of the CAA office and method of email contact with CAA.
10. Good Practice Database
The CAA website is maintained and updated as necessary by CAA staff supported by the
Department of IT of MoE.
170
APPENDIX 20: DOCUMENT CONTROL AND MANAGEMENT
DOCUMENT CONTROL AND MANAGEMENT
RESPONSIBLE DOCUMENT DATE OF REVISION

OFFICE
CAA POLICIES AND PROCEDURES OCT. 31ST, 2019

MANUAL
171

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1. INTRODUCTION AND BACKGROUND ............................................................................................................................. 6

HISTORICAL OVERVIEW .............................................................................................................................................. 7

VISION, MISSION, CORE VALUES, STRATEGIC GOALS ................................................................................................. 8

ORGANIZATION AND GOVERNANCE........................................................................................................................... 9

STRATEGIC PLANNING .............................................................................................................................................. 10

POLICIES AND PROCEDURE ....................................................................................................................................... 11

PREFACE FOR POLICIES ............................................................................................................................................. 11

2. ACCREDITATION POLICIES AND PROCEDURES FOR INSTITUTIONS ............................................................................. 12

STANDARDS FOR LICENSURE AND ACCREDITATION ................................................................................................. 12

E-LEARNING STANDARDS FOR LICENSURE AND ACCREDITATION ............................................................................ 13

PROCEDURAL MANUALS FOR INITIAL INSTITUTIONAL LICENSURE, RENEWAL OF INSTITUTIONAL LICENSURE,

GRADUATE EDUCATION ADMISSION REGULATIONS FOR LICENSED INSTITUTIONS ................................................ 14

CRITERIA FOR TEACHING HOSPITALS AND MEDICAL / CLINICAL FACULTY ............................................................... 14

TEACH OUT POLICY FOR CLOSED INSTITUTIONS OR PROGRAMS ............................................................................. 15

COMPLAINTS AGAINST INSTITUTIONS ...................................................................................................................... 15

JOINT REVIEWS WITH OTHER QUALITY ASSURANCE AGENCIES ............................................................................... 17

POLICY ON CHANGE OF OWNERSHIIP OR CONTROL OF AN INSTITUTION ............................................................... 18

FINANCIAL MATTERS RELATING TO INSTITUTIONS .................................................................................................. 18

SPECIAL VISITS TO INSTITUTIONS ............................................................................................................................. 18

PRE-VISIT ACTIVITIES: RECEIPT OF APPLICATIONS ................................................................................................... 20

PRE-VISIT ACTIVITIES: DETERMINING ERT ............................................................................................................... 20

FORMS ASSOCIATED WITH THE PROCESSES OF REVIEWS ........................................................................................ 20

HANBOOK FOR EXTERNAL REVIEW TEAMS .............................................................................................................. 21

CONFLICT OF INTEREST ............................................................................................................................................. 22

HONORARIA POLICY FOR ERTS ................................................................................................................................. 22

TRAVEL ARRANGEMENTS FOR ERTS ......................................................................................................................... 22

4. COMMISSION ADMINISTRATIVE PROCEDURES ........................................................................................................... 24

ETHICAL OBLIGATIONS OF COMMISSIONERS AND COMMISSION STAFF ................................................................. 24

COMPLAINTS AGAINST THE COMMISSION ............................................................................................................... 24

INSTITUTIONAL LICENSURE AND PROGRAM ACCREDITATION PROCEDURES .......................................................... 24

BUDGETING AND FINANCE ....................................................................................................................................... 25

PROFESSIONAL DEVELOPMENT ................................................................................................................................ 25

DOCUMENT CONTROL, MANAGEMENT, CONFIDENTIALITY, AND DISPOSITION ..................................................... 25

HEALTH AND SAFETY POLICY .................................................................................................................................... 26

RISK MANAGEMENT POLICY ..................................................................................................................................... 26

SIGNING AUTHORITY ................................................................................................................................................ 27

5. PERSONNEL POLICIES AND PROCEDURES .................................................................................................................... 28

VACANT POSITIONS .................................................................................................................................................. 28

ORIENTATION OF NEW COMMISSIONERS ................................................................................................................ 28

WORKING HOURS/ HOLIDAYS .................................................................................................................................. 29

POSITION DESCRIPTIONS .......................................................................................................................................... 29

ANNEX 1 Initial Accreditation Process ............................................................................................................... 32

ANNEX 2 Renewal of Accreditation Process ...................................................................................................... 33

ANNEX 3 Initial Licensure Process ...................................................................................................................... 34

ANNEX 5 Substantive Change Process ............................................................................................................... 36

ANNEX 6 CAA Strategic Plan 2020-2024 ............................................................................................................ 37

ANNEX 7 Council of Commissioners (COC) ........................................................................................................ 42

APPENDIX 1: CAA ORGANIZATIONAL CHART ....................................................................................................... 45

APPENDIX 2: CAA POSITION DESCRIPTIONS ........................................................................................................ 46

APPENDIX 3: STRATEGIC ADVISORY COMMITTEE ............................................................................................... 59

APPENDIX 4: CRITERIA FOR TEACHING HOSPITALS ............................................................................................. 60

APPENDIX 5: TEACH OUT ..................................................................................................................................... 65

APPENDIX 6: COMPLAINTS .................................................................................................................................. 69

APPENDIX 7: CHANGE OF OWNERSHIP OR CONTROL OF AN INSTITUTION ........................................................ 71

APPENDIX 8: RECEIPT OF APPLICATIONS ............................................................................................................. 73

APPENDIX 10: CAA FORMS .................................................................................................................................... 80

APPENDIX 11: GUIDE FOR ERT MEMBERS .......................................................................................................... 134

APPENDIX 12: PROCEDURES .............................................................................................................................. 149

APPENDIX 13: ENTITLEMENTS OF ERTS............................................................................................................... 153