NURS FPX 4015 Assessment 1

NURS FPX 4015 Assessment 1 Waiver and Consent Form

Student Name

Capella University

NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care

Prof. Name:

Date

Waiver and Consent Form

Institution: Capella University Course: NURS4015 or NURS-FPX4015

I, __________________ (“Participant”), voluntarily agree to participate as a simulated patient in a health assessment video demonstration conducted by __________________ (“Student”), a nursing student at Capella University.

This agreement outlines the rights, responsibilities, and terms of participation. By signing, I acknowledge my understanding and acceptance of the provisions stated below.

Purpose of Participation

The purpose of this simulation is to support educational learning at Capella University. The recorded materials, hereafter referred to as Content, will be used exclusively for instructional purposes. These may include:

• Demonstrating health assessment skills for academic review.
• Completing an academic comprehensive assessment with a SOAP (Subjective, Objective, Assessment, and Plan) note, aligned with course requirements.
• Providing hypothetical health-related information for a simulated clinical practice activity.

I also understand that I waive the right to preview or approve the Content prior to its educational use.

Content

I give permission to be video recorded for the production of the Content. This includes granting consent for the Student to collect and document information necessary for completing the SOAP note.

For clarity, Content refers to:

Disclosures

• The information presented in the Content is strictly for academic demonstration and is not professional medical advice or diagnosis.
• The Student and Participant are not required to share or disclose actual medical histories. Except for age and gender, details may be fictionalized for the purpose of simulation.
• I acknowledge that if certain physical measurements (e.g., blood pressure, temperature, or pulse) are collected during the demonstration, these may reflect my real health status.

Voluntary Consent and Use

I willingly grant Capella University the unrestricted, royalty-free, and irrevocable right to use the Content for educational purposes. The Content may be shared with instructors, evaluators, and other faculty or staff within the university.

By signing this waiver, I:

1. Relinquish the right to review or approve the Content prior to its use.
2. Waive any claims for damages, compensation, or concerns relating to editing, distortion, or representation of my likeness, image, voice, or words within the Content.

Rights and Ownership

All Content generated through this agreement becomes the exclusive property of Capella University. This includes:

• Full ownership of recordings, data, and materials.
• Rights to reproduce, distribute, display, or otherwise utilize the Content for academic purposes.

I release Capella University from all claims relating to privacy, publicity rights, or defamation that may arise from the creation or use of the Content. Furthermore, I discharge the University from liability for any potential injuries, damages, or expenses incurred due to participation.

Waiver and Release

I hereby release and hold harmless Capella University, its affiliates, trustees, employees, contractors, students, and representatives from any and all liabilities, claims, or actions related to:

• The recording, display, or distribution of the Content.
• Any damages, costs, or personal injuries that may result from participation in the activity.

Governing Law and Venue

This agreement is legally governed under the laws of the State of Minnesota. Any disputes arising from this Waiver shall be resolved exclusively in the state or federal courts located in Minnesota.

Acknowledgment and Agreement

By signing below, I confirm that I am at least 18 years of age, that I have fully read this Waiver and Consent Form, and that I voluntarily agree to its terms without coercion.

Student

Signature: _________________________ Date: 24-02-2025 Printed Name: _______________________

Participant

Signature: _________________________ Date: 24-02-2025 Printed Name: _______________________

References

Capella University. (2025). Waiver and consent policy for simulated health assessments. Capella University Academic Resources. American Nurses Association. (2023). Ethical considerations in patient simulations. ANA Publications. Minnesota Office of the Revisor of Statutes. (2024). Minnesota Statutes: Education and consent laws.

NURS FPX 4015 Assessment 1 Waiver and Consent Form