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

Institution and Course Information

Institution: Capella University

Course: NURS4015 or NURS-FPX4015

Participant Consent Agreement

I, ___________________ (“Participant”), voluntarily agree to participate as a mock patient in the health assessment video demonstration conducted by ___________________ (“Student”), who is currently enrolled in the nursing program at Capella University.

In exchange for the educational experience, I accept and agree to the terms outlined in this consent and waiver form.

Purpose of Participation

The purpose of this agreement is to ensure that all recorded materials are used strictly for academic and educational purposes. These include:

• Demonstrating health assessment skills and clinical techniques for faculty evaluation.
• Completing a detailed assessment using a SOAP (Subjective, Objective, Assessment, Plan) note in alignment with course requirements.
• Providing simulated patient information to support clinical practice exercises.

I acknowledge that I do not have the right to review or approve the final content before its educational use by Capella University.

Content and Recording Agreement

The term “Content” encompasses all video recordings, images, likenesses, voice recordings, verbal interactions, and data collected during the mock health assessment. This includes any information used to complete the SOAP note.

I grant permission for my participation to be recorded, recognizing that all recordings will serve only for academic purposes associated with the course objectives.

Information Disclosure Policy

I understand that:

• All health-related information shared is for educational demonstration and does not constitute professional medical advice or a clinical diagnosis.
• I am not required to provide real medical history or sensitive personal health data unless I voluntarily choose to do so.
• Certain demographic details, such as age and gender, may be disclosed, while other information can remain hypothetical for the simulation.
• Any vital signs or health measurements recorded during the demonstration may reflect my actual status.

Voluntary Consent and Content Usage

By signing this waiver, I grant Capella University irrevocable permission to:

• Use, distribute, reproduce, display, and publish the Content for academic purposes.
• Share the Content with the course instructor and other authorized faculty members for evaluation.

I acknowledge that I waive the following rights:

• Reviewing or approving the Content prior to its use.
• Pursuing claims for damages related to the alteration, editing, or reproduction of my recorded likeness or voice.

Rights and Ownership of Content

I understand that Capella University retains full ownership of all Content. Any recordings, data, or materials created as part of this educational activity are the sole property of the University.

By signing this waiver, I also release the University from:

• Claims regarding ownership, creation, or use of the Content, including privacy, defamation, or publicity concerns.
• Liability for any injuries, damages, or costs associated with participation in the educational activity.

Waiver and Release of Liability

I voluntarily release Capella University, including its trustees, faculty, students, employees, agents, and contractors, from any liabilities, claims, or legal actions arising from the creation, distribution, or use of the Content. This ensures that I will not pursue legal action related to my participation.

Governing Law and Jurisdiction

This agreement is governed by the laws of the State of Minnesota. Any disputes arising from this waiver will be addressed in the state or federal courts located within Minnesota.

NURS FPX 4015 Assessment 1 Waiver and Consent Form

The undersigned confirm that they are over the age of 18, have read and understood the conditions of this waiver, and voluntarily agree to participate in the activity.

Role	Printed Name	Signature	Date
Student	__________________	______________	24-02-2025
Participant	__________________	______________	24-02-2025

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. ANA.

Capella University. (2023). School of Nursing and Health Sciences: Academic guidelines. Capella University.

U.S. Department of Health & Human Services. (2020). Health information privacy: HIPAA basics. https://www.hhs.gov/hipaa