Occupations and Terms of Reference › Ethics committee secretary
Universal terms of reference · POS-019 · version 1.0 · status: draft · next review 2027-10-27
Ethics committee secretary
To run the ethics committee administration, so that research and clinical ethics reviews are timely, complete, recorded and fair.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You support the ethics committee. You manage applications, agendas, minutes and records, and make sure reviews happen on time and decisions are recorded and followed up.
Reports to: Medical director.
Leads or supervises: No direct reports.
What you do on a typical day
- Receive and check applications for completeness.
- Prepare agendas and papers for meetings.
- Record decisions and send letters on time.
- Track conditions and follow-up reports.
- Keep records secure and retained as required.
Working conditions and demands
- Works to tight meeting schedules.
- Handles confidential and sensitive information.
- Needs to be impartial and accurate.
What good looks like
- Applications are reviewed on time.
- Minutes and decisions are issued promptly.
- Records are complete and secure.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Every decision that affects patient safety is made on evidence and recorded.
- Patient safety and quality come before financial targets; no trade-off that puts patients at risk is accepted.
- Every staff member can raise a concern without fear of reprisal, and every concern is answered.
- Legal, licensing and accreditation duties are known, owned and reviewed.
- Finances, people and information are managed openly and within the law.
- Mandatory training and policies apply to the executive as much as to frontline staff.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-019 |
| ISCO-08 | 3344 (skill level 4) |
| ESCO | to map |
| Department | Support |
| Facility types | Hospital, Ambulatory |
3. Reporting line and working relationships
Reports to: POS-012. Supervises: .
| Works with | Nature of the relationship |
|---|---|
| Medical director | Clinical ethics cases and committee agenda. |
| Clinical governance lead | Research and audit ethics. |
| Data protection officer | Consent and data in research. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Applications | Checks applications and passes them to the committee on time. | Applications logged; review dates set | Monthly | C-01 · C-02 | T-04 | POL-DATA | 2 |
| Meetings | Prepares agendas and papers, and keeps minutes. | Papers issued before meetings; minutes approved | Monthly | C-01 | T-04 | – | 2 |
| Decisions | Issues decisions and tracks conditions to completion. | Decision letters issued on time; conditions tracked | Monthly | C-02 | T-05 | – | 2 |
| Records | Keeps records secure and retained as required. | Retention schedule followed; access logged | Quarterly | C-03 | T-04 | POL-DATA | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Administrative procedures within the committee's terms of reference | Matters outside the committee's remit (medical director) |
| Timing of review sessions within the committee's schedule | Applications with unresolved ethical concerns (committee chair) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Secretarial, administration or health records qualification | No | Lifetime |
| Q-02 | Research ethics or ethics committee training | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Committee or administrative experience in a health or research setting | 3 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | C-01 · C-02 · C-03 |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | C-02 |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | – |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | – |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Committee administration and records | Keeps accurate records | Runs committee administration | Designs the administrative process | Records audit | Every 12 months | T-04 |
| C-02 | Ethics review processes | Knows the review steps | Checks applications against standards | Supports consistent ethics decisions | Review audit | Every 12 months | T-04 · T-05 |
| C-03 | Confidentiality and data handling | Protects confidential papers | Manages secure records | Designs secure record systems | Records audit | Every 12 months | T-04 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Applications reviewed within the set timeframe | 100% | application log | Monthly |
| PI-02 | Minutes issued within agreed days | 100% | minutes register | Monthly |
| PI-03 | Conditions tracked to closure | 100% | condition tracker | Quarterly |
| PI-04 | Records complete and secure | 100% | records audit | Annually |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Ethics committee secretary | 3 years (recommended) | Q-01 | C-01 practitioner, C-02 practitioner | T-04 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |