DEPARTMENTAL
INTERNAL AND
EXTERNAL
REVIEW
GUIDELINES
DIVISION OF
STUDENT AFFAIRS
Adopted January 2015
Updated November 2018
TABLE OF CONTENTS
INTRODUCTION I 2
PHASE I: FORMATION OF THE INTERNAL REVIEW TEAM I 2
PHASE II: SELF-STUDY REPORT I 3
PHASE III: FORMATION OF THE EXTERNAL REVIEW TEAM I 4
PHASE IV: EXTERNAL REVIEW I 5
PHASE V: ACTION PLAN AND IMPLEMENTATION I 6
APPENDIX A: EXTERNAL REVIEWER APPROVAL MEMO TEMPLATE I 7
APPENDIX B: SAMPLE CONSULTANT ACCEPTANCE LETTER I 8
APPENDIX C: DOCUMENT CHECKLIST I 9
APPENDIX D: SELF-STUDY REPORT GUIDELINES I 11
APPENDIX E: EXTERNAL REVIEW TEAM FINAL REPORT OUTLINE I 12
APPENDIX F: DEPARTMENTAL IMPLEMENTATION PLAN TEMPLATE I 14
APPENDIX G: DIRECTOR’S EXTERNAL REVIEW SUMMARY REPORT TEMPLATE I 15
INTRODUCTION
The departmental internal and external review is designed to be a collaborative process that will
enhance the mission of the Division of Student Affairs by providing opportunities for departments
to assess, share and improve their impact, services and quality of work. Each program review is an
opportunity for the department to take a comprehensive and critical look at the unit, to clearly state
and then evaluate strengths and weaknesses, and to determine needed future action. This process
empowers departments within the Division of Student Affairs to think critically about their work and
the impact it is making on the student experience at The University of North Carolina at Pembroke.
Phase I: Formation of the Internal Review Team (Self-Study Team)
I. Internal Review Team
The Internal Review Team will consist of four to ve team members. The ideal self-study team
includes representatives from various populations on campus; student (1), faculty (1), student affairs
staff member outside the department undergoing the study (1) and member from the department
under review (1). The team member from the department being reviewed should NOT be in an
administrative position within the department (avoid director, associate director, assistant director as
representatives). The self-study team leader (1) can be staff/faculty so long as the individual has been
CAS trained.
Once the team leader contacts and conrms the participating members commitment to the process
a meeting is set. The following criteria will be considered when establishing the meeting protocols for
an internal review.
A. Initial meeting requires the team to:
1. Review the CAS guidelines for the department being reviewed
2. Review artifacts shared by the department for the review
3. Practice rating scales to establish rating criteria and increase inter-rater reliability
4. Set deadline for when all material needs to be reviewed and ranked in the CAS rubric
and submitted to the team chair
5. Set a date to visit the ofce space of the department under review
B. Second meeting requires the team to:
1. Share ranking sheets within the team; discuss any discrepancies between the rankings
2. Complete Work Form A; Assessment, Ratings and Signicant Items in the CAS self-
assessment guide (SAG) outlining discrepancies, strengths, needed improvements for each
standard and guideline, and generates a list of items that merit follow up
3. Establish how and when the summary report for the department will be completed
C. Final meeting requires the team to:
1. Review and approve the self-study summary report
2. Invite members of the department to the nal meeting to discuss the report and in what
format the outcome will be shared to the division and campus
3. Assist the department in completing CAS Work Form B: Follow Up Actions if the
department wishes to begin that discussion
4. Review the department plan for the external review and share any/all relevant
documents (including summary ratings) with the department
The nal self-study report, follow up action plan and all relevant data from the review process will
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be presented to the vice chancellor for Student Affairs and the executive staff for approval. Included
in this material should be a timeline for a) completing the action plan, b) the external review and c)
deadline for completion of the review process with the date of when the review cycle begins again.
Phase II: Self-Study Report
I. Data and Artifact Collection
The departmental director and members of his/her staff will collect all relevant data to help tell the
department’s story to the external reviewers. Because of the need to understand the full scope of
the department’s activities, all external reviewers should be provided copies of the department’s
CAS internal review report as well as any additional information (e.g., performance standards, policy/
procedural handbooks, marketing materials, organizational chart, job descriptions, etc.)
See Appendix C- Document Checklist
II. Development of the Self-Study Report
The self -study report may be based on existing data, but may also require the collection of new data
in order to assess concerns such as student satisfaction, student learning, retention and persistence,
etc. Each department will prepare an in-depth self-study report prior to the on-site visit by the
external review team. The self-study report will contain the following:
A. Table of Contents
B. Executive Summary
C. An introduction to the department including history and organizational framework
D. Summary of relevant data
E. Overview of the following standards: (adapted from CAS Self-Assessment Guides)
• Departmental mission
• Departmental programs
• Organization and leadership
• Human resources
• Ethics
• Law, Policy and governance
• Diversity, equity and access
• Institutional and external relations
• Financial resources
• Technology
• Facilities and equipment
• Assessment and evaluation
F. Key issues to be addressed by external review panel (challenges, concerns, etc.)
Additional resources or supporting documentation may be included in the self-study appendix.
To the extent possible, the above guidelines should be addressed with supporting data. In some
departments, professional associations may have already developed detailed standards for
departmental review. In such cases, the self-study and site visit should incorporate these guidelines
and criteria.
See Appendix D - Self-Study Report Guidelines
III. Self-Study Submission
The departmental director will submit a nal draft of the self-study report to the vice chancellor
no later than three weeks prior to the on-site external review. All documents should be shared
electronically. The director will then share the self-study report with all members of the external review
team two weeks prior to the on-site visit.
Phase Ill: Formation of the External Review Team
I. External Review Team
The external review team will consist of two external experts in the eld of work most closely
aligned with the mission and purpose of the department under review. The following criteria will be
considered when identifying external reviewers:
A. The reviewer must have experience as a staff member in a similar program at another institution.
B. Experienced reviewers with national reputations in their elds should be selected.
C. Reviewers should be familiar and comfortable with UNC Pembroke, but removed enough to avoid
any potential bias or conicts of interest.
Based on the criteria above, the process for forming and selecting reviewers is as follows:
A. The departmental director will compile a list of two-to-three potential external reviewers, including
reviewer names, current position/employer, rationale for their inclusion and the estimated cost for
their visit.
See Appendix A - Reviewer Approval Memo Template.
B. This memo will be presented to the vice chancellor for Student Affairs and the executive staff for
approval. The VC may also contribute names for consideration based on current leaders in the eld of
work.
C. Once the external review team nominee list is approved, the director will extend a formal invitation
to two of the nominees asking if they are willing to participate in the external review. The consultants
must return an acceptance letter.
See Appendix B - Sample Consultant Acceptance Letter.
D. Departments should use departmental funds to support the external review and/or consult with
the vice chancellor to identify any additional funds that may be available.
E. The departmental director/staff will coordinate all logistics regarding their visit including:
1. Develop the itinerary;
2. Distribute the on-site itinerary to review team and other campus administrators;
3. Schedule interview times for constituents to meet with members of the review team;
4. Prepare all necessary materials and reserve rooms and equipment;
5. Facilitate all travel, meals, and other logistics;
6. Serve as the site host for the review team’s campus visit; and
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7. Oversee all communication with the review team prior to and after their visit.
Phase IV: External Review
I. Role and Purpose of the External Review Team
A team of external reviewers will conduct a minimum two day on-site review. The review team should
consist of at least two external reviewers who have not been employed by the department under
review. It is recommended that the university reviewers are familiar with the work of the division and/
or the department undergoing review. The external reviewers should be experts in the eld and/
or functional areas and their role as reviewers is to provide expert, unbiased, professional opinion
regarding the performance of a department after extensive research and interviews conducted during
and before their site visit.
II. The Self-Study Report
As mentioned above, the director will share the self-study report electronically with all members of
the external Review Team two weeks prior to the on-site visit. The self-study should also include any
key issues, concerns or questions the department would like the external review panel to focus on
while on campus.
III. Site Visit Itinerary
A detailed agenda for the external reviewer’s visit should be established by the director prior to the
on-site visit. The external review team, vice chancellor, executive team and department members
should receive the itinerary no less than two weeks prior to the on-site review. During the site visit, the
external review team should meet with all of the department’s key stakeholders. This may include (but
is not limited to) members from the following groups:
• Departmental Staff (this includes exempt/non-exempt/graduate staff)
• Campus partners (colleagues within and outside of the division)
• Upper Administration
• Community partners
• Students
• Customers
• Alumni
All information gathered during the review process is designed to support and enhance the
efciency and effectiveness of the department. Therefore, information shared during individual
and group interviews are for the use of the review team. It is important that we maintain a safe and
welcoming environment for staff to share their informed perspectives. Statements made during the
group interviews are not for public consumption and should be valued, respected and treated with a
spirit of condentiality.
Additionally, the review team should be provided ample time for meals, time spent with the
departmental director and time spent at the conclusion of the review to begin summary conversations
for the purposes of the external review report. The on-site will conclude with a summary meeting
including the review team, departmental director, vice chancellor, and executive staff as needed.
IV. External Review Report
Within four weeks of the external review team’s campus visit, the reviewers are expected to provide
a written assessment of the department, including departmental areas of excellence, and areas
for improvement. The external review team should also include any other information they deem
appropriate, including recommendations for future practice (both within the department and within
the larger university structure).
See Appendix E- External Review Report Outline
This written report will be shared initially with the departmental director, vice chancellor for Student
Affairs, and executive team.
A follow-up meeting will be held a week later to discuss next steps.
Phase V: Action Plan and Implementation
After the external review panel’s report has been received, the department will develop a summary
report and an action plan in response. The action plan should correlate directly with the department’s
strategic plan and should include the following:
• Proposed goals
• Metrics to measure progress
• Timeline for completion
• Responsible parties
• Implementation strategy
• Evaluation process
See Appendix F- Summary report outline
See Appendix G- Departmental Implementation plan
The action plan should be submitted to the vice chancellor for review and approval within one
month of the receipt of the external review team’s ndings. Once the plan has been approved, the
department will commence with implementation of the plan and will report on progress in each year’s
annual report.
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APPENDIX A: EXTERNAL REVIEW - REVIEWER
APPROVAL MEMO TEMPLATE
Date: [current date]
TO: Dr. Lisa Lewis Schaeffer.
Vice Chancellor of Student Affairs
From: [Director’s name]
[Title]
RE: External Reviewer Approval
Action Needed:
Permission is requested to hire [ll in external reviewer name(s), title(s), and organization(s) here] as
the external reviewer for [department name].
Justication:
For example only - include a description that relates to you and your department here--
[External reviewer name here] has seventeen plus years of experience as a health education
practitioner. As indicated in her biography and resume, she has served as a consultant for the review
of health and wellness programs at over 20 institutions using the Guidelines for a College Health
Program, the ACHA Standards of Practice for Health Promotion in Higher Education, and the CAS
Professional Standards for Higher Education.
[External reviewer] would work a full [ll in the number of days here] during her stay. The fees incurred
are estimated as follows:
Consultation fee: $ xxx.xx
Airfare: Up to 2 nights at Hotel: $ xxx.xx
On and Off campus (meals): Mileage for personal vehicle: $ xxx.xx
Transportation (to and from airport): $ xxx.xx
Total Estimated Cost: $ xxx.xx
Funds to support [external reviewer’s consultation have been allocated, in full, in [department name]
FYIS budget.
Attachment: Resume of external reviewer
APPENDIX B: EXTERNAL REVIEW SAMPLE CONSULTANT
LETTER
[Current date here]
Director’s Name Title
UNC Pembroke
P.O Box 1510
Pembroke, N.C. 28372-1510
Dear:
I have agreed to serve as a member of an external review team during a [ll in number of days here]
day visit to UNC Pembroke scheduled for [ll in dates here]. The basis of my visit is to serve as a
consultant to [ll in department name here] in conducting a comprehensive review of operations
using the CAS Professional Standards for Higher Education. The department has asked that we
provide special emphasis on the following areas:
1. [ll in appropriate specics here]
2. [ll in appropriate specics here]
3. [ll in appropriate specics here]
Although the schedule is still being nalized, a draft copy of my itinerary is attached. The review
will be based on my reading of the materials sent to me prior to the on-campus visit, review of the
website, analysis of the results of the Internal review report, and interviews conducted during the
site visit. Upon completing the visit, an initial draft report will be provided to which you can respond
before the report is nalized. I understand that the deadline for the nal written report is [ll in the
date the report is due here].
As compensation for this visit, I have agreed to UNC Pembroke’s offer of a $xxxx.xx honorarium plus
travel expenses, meals and overnight accommodations for the dates of the visit, [ll in the site visit
dates here]. I understand that UNC Pembroke’s accounting procedures require that payment be
rendered only once services are received and that my stipend will be disbursed following receipt
of the nal written report. I have included my name and address below for your processing through
procurement.
Best Regards,
External reviewer’s name
Address
Phone number(s)
Email address
Cc: Dr. Lisa Lewis Schaeffer, Vice Chancellor of Student Affairs
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APPENDIX C: DOCUMENT CHECKLIST SUGGESTIONS
Council for the Advancement of Standards (CAS)
• SAG (CAS Self-Assessment Guide)
Department Information
Mission statement
Department program goals
Department history (e.g. original concept proposal for the department, documentation regarding the
establishment of department, etc.)
Organizational Chart
UNCP Student Affairs organizational chart
Department organizational chart
Department staff list
Staff (Including Students) Documentation
• CV/Resumes
• Director
• Assistant director
• Coordinators
• Others, as appropriate
• Training documents
• Current job descriptions
• Expectations/Roles
Other Administrative Documents
• Department budget and other scal information (e.g. major requisition documentation,
breakdown of expenditures, internal forms/training, etc.)
• Departmental agreements
• Liability insurance coverage
• Staff handbook/standards of practice
• Documentation of internal processes
Historical Documents
• Annual reports (current and previous years)
• Annual planning and assessment documents
• Pertinent other reports (e.g., Ofce of Institutional Research documents, assessment-specic
reports/results)
Program/Service Documentation
• Program/service lists and descriptions
• Departmental promotional/marketing/informational materials
• Student demographics (Students enrolled in program, Prole of students served by the department)
• Other documentation critical to understanding the scope of the department’s programs/ services
o Documentation of external collaborations
o Intake forms that deal with your particular population, for example:
Client Information Examples
Client Input Sheet
Database Functions Access Form
Daily Contact Log Example
Client Agreement Form
Information specic to your particular population
e.g., Roommate Survival Guide, Take Back the Night Pamphlet, copies of pertinent
standards (e.g., CAS, ACUHO-i), etc.
External Review Documents
The external reviewer should be sent copies of the internal documents (examples listed
above), plus the following (as appropriate) to assist in the external review:
• University mission statement
• Division of Student Affairs and Enrollment Management mission statement
• The departmental internal review report
• Guidelines for preparation of the departmental external review report
• Submission of nal external review report completion date
• External review report template
• Sample consultant letter
• Departmental demographics such as:
Size of department (number of staff, number of ofces, size of budget) growth/compression
trends
Other applicable demographic information (e.g., staff turnover rate, ratio of staff to student
worker, ratio of computers to staff, range of staff experience/skill sets, etc.)
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APPENDIX D: SELF-STUDY REPORT GUIDELINES
Each department will prepare an in-depth self-study report prior to the on-site visit by the external
review team. The self-study report will contain the following:
Table of Contents
Executive summary: A one page document highlighting the contents of your self-study. Key data
points/strengths/challenges should be addressed in this portion.
An introduction to the department: Include departmental history and organizational framework
(org charts), constituents served, key data points, learning outcomes, etc.
Summary of relevant data: Include data related to learning outcomes, program outcomes, usage,
access, certications, memberships, retention, etc.
Overview of the following standards:
(Adapted from CAS Self-Assessment Guides, August 2013)
• Departmental mission
• Departmental programs
• Organization and leadership
• Human resources
• Ethics
• Law, rolicy and governance
• Diversity, equity and access
• Institutional and external relations
• Financial resources
• Technology
• Facilities and equipment
• Assessment and evaluation
Each of these standards is explained in detail within each department’s CAS self-assessment guide.
Each member of the external review team will receive the SAG to inform their practice. Please utilize
the SAG to provide information regarding each of the standards above in your self-study.
Key issues: include any internal or external challenges/concerns facing your department, staff, etc.
that you would like for the review team to examine further.
APPENDIX E: EXTERNAL REVIEW TEAM FINAL REPORT
OUTLINE
Instructions
Based on the ndings from the self-study report and the campus visit, the external review team is
asked to assess the department’s performance and offer suggestions for future improvement. The
external review members are asked to develop a joint written report. The suggested outline for the
external review report is located below, however the external review team members are encouraged
to include any issues or topics they deem necessary in order to create a comprehensive report.
(Based in part on CAS Work Form A: Assessment, Ratings, and Signicant items, August 2013.)
Step I: Executive Summary
Please provide a narrative addressing the following:
A. Areas of Excellence - describe what the department does well. Include how this supports the unit’s
mission and goals.
B. Areas for Improvement - describe the areas that the department should improve Identify the
reasons that these areas need improvement.
Step II: Assessment of Signicant Items
Part Number Part Discrepancies Strengths Needed
Improvements
1 Mission
2 Program
3 Organization and
Leadership
4 Human Resources
5 Ethics
6 Law, Policy and
Governance
7 Diversity, Equity
and Access
8 Institutional and
External Relations
9 Financial
Resources
10 Technology
11 Facilities and
Equipment
12 Assessment and
Evaluation
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External Review members are also encouraged to submit complete CAS Self-Assessment Guides for
each standard.
Step III: External reviewers will recommend follow up actions and justications
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Step IV: Reviewers Concluding Comments
Please share any additional comments that are for the good of the department, division or university.
Please note that this written report will be distributed to members of the department, the vice
chancellor of Student Affairs and the executive team.
APPENDIX F: DEPARTMENTAL IMPLEMENTATION
PLAN
This form concludes the self-assessment process and calls for action to be taken as a consequence of
study results. Write a brief action plan statement in the spaces below for each part in which action is
required.
Part 1: Mission
Part 2: Program
Part 3: Organization and Leadership
Part 4: Human Resources
Part 5: Ethics
Part 6: Law, Policy and Governance
Part 7: Diversity, Equity and Access
Part 8: Institutional and External Relations
Part 9: Financial Resources
Part 10: Technology
Part 11: Facilities and Equipment
Part 12: Assessment and Evaluation
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APPENDIX G: DIRECTOR’S EXTERNAL REVIEW
SUMMARY REPORT TEMPLATE
NOTE: This document is a general template. Please best structure the Summary Report as it pertains
to your department.
[Department name] External Review Summary Report
After reviewing the external review report for [department name] and making some comparisons to
the internal review committee report, the following conclusions were drawn and recommendations for
moving the department forward are as follows:
[Make a statement about looking at both internal and external reports. For example: “Overall, the
recommendations made by the external reviewer and the internal review committee were fairly
congruent.”] Then go on to discuss where the reports had similar ndings, briey. For example: Both
reports indicate that [ll in the specics - this may be a paragraph or two, or simple a sentence or
so if the reports don’t converge. If the reports don’t converge, explain that and why they don’t.] An
example synthesizing of a non-converging nding would be “While the internal review committee
did not prioritize the formation of an advisory board as one of their top seven recommendations
for immediate consideration, the external reviewer’s recommendation for the department to move
forward with the creation of an advisory board would be a good rst step in exploring in more detail
what the true needs of the department are.”
[Highlight the important stuff] for example: “Both reports suggest that more stafng is needed to
provide the targeted student population with the best possible programs and services. [Briey make
the argument of the most salient points from the reports - identifying which report (if not both) the
point stems from]
In conclusion, make your concluding remarks.
A page or two for this document is sufcient. Think of it as a combined executive summary of the
Internal and External Review reports. This report must be accompanied by the action steps and
timeline.
Submitted by:
Your Name
Date
Title
DIVISION OF STUDENT AFFAIRS
ONE UNIVERSITY DRIVE
PEMBROKE, NC 28372
PHONE | 910.521.6226
FAX | 910.521.6272
LOCATION | UC ANNEX, SUITE 210
EMAIL | STUDENTAFFAIRS@UNCP.EDU
STUDENTAFFAIRS.UNCP.EDU
/UNCP STUDENT AFFAIRS
This publication is available in alternative formats upon request. Please contact the
Accessibility Resource Center, D.F. Lowry Building, Room 107, or call 910.521.6695.
Revised 181031
