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
This Waiver and Consent Form serves as a formal record of the voluntary agreement of ___________________ (“Participant”) to act as a simulated patient in a recorded health assessment exercise conducted by ___________________ (“Student”), a nursing learner enrolled at Capella University. By signing this document, the Participant confirms comprehension of the purpose, scope, and legal implications associated with their involvement in this academic activity. Participation is strictly voluntary, and the Participant may withdraw at any time without penalty.
Purpose of the Waiver
What is the purpose of this waiver?
The primary purpose of this waiver is to clarify the educational nature of the activity and to outline the authorized use of all recorded materials and related information (collectively referred to as “Content”). The Content generated through this activity is intended exclusively for academic and instructional objectives within the nursing program.
Specifically, the recorded materials and related data will be used to:
- Demonstrate and evaluate clinical nursing assessment skills.
- Support the completion of coursework, including the preparation of a SOAP (Subjective, Objective, Assessment, Plan) note.
- Provide structured simulation data for academic exercises, skill validation, and critical reflection.
The Participant acknowledges that they will not have the right to review, modify, or approve the Content prior to its use in academic contexts. This approach ensures integrity in educational assessment and aligns with best practices in nursing education (American Nurses Association [ANA], 2023).
Content Authorization
What constitutes “Content” under this agreement?
The Participant consents to the creation, collection, and academic use of the following types of Content:
| Component | Description |
|---|---|
| Video Recording | Any digital recording capturing the Participant’s image, voice, facial expressions, or physical demonstration of clinical tasks. |
| Verbal Statements | All spoken responses, explanations, or dialogue provided by the Participant during the simulation. |
| Health-Related Information | Data collected for academic demonstration purposes consistent with learning objectives. |
The Content is restricted to what is reasonably necessary to fulfill the educational objectives of the nursing assessment. Any use outside these parameters is not authorized.
Disclosures
Is this activity considered medical care?
No, this activity is purely educational and does not constitute medical advice, diagnosis, treatment, or evaluation. The simulation is designed solely for teaching and assessment purposes.
Is real medical history required?
No, neither the Student nor the Participant is required to disclose actual medical history or confidential personal health information. Except for basic demographic details, such as age and gender, all other case specifics may be adapted or fictionalized to meet academic needs. This methodology aligns with ethical standards in nursing education and promotes confidentiality and safe learning environments (ANA, 2023).
Voluntary Consent and Authorized Use
What rights are granted to Capella University?
By signing this form, the Participant provides Capella University with a perpetual, royalty-free license to:
- Use, reproduce, distribute, publish, and display the Content.
- Share the Content with faculty, instructors, staff, or evaluators for academic review.
- Retain the Content as part of institutional educational records.
What rights are waived?
The Participant waives the right to:
- Review or approve the Content before its academic use.
- Receive financial compensation for the creation or academic use of the Content.
- Pursue legal claims for damages arising from authorized academic use of the Content.
Rights and Ownership
Who owns the recorded material?
All Content produced under this agreement is the sole intellectual property of Capella University. Ownership includes archival rights, academic dissemination, and use in future teaching or program evaluation activities.
What claims are released?
The Participant releases Capella University from any claims related to:
- The creation, modification, or dissemination of the Content.
- Alleged violations of privacy or publicity rights.
- Claims of defamation, reputational harm, or other grievances arising from authorized academic use.
Waiver and Release of Liability
The Participant formally releases Capella University, its trustees, faculty, employees, students, contractors, and affiliated representatives from any liability, claims, or financial obligations that may arise due to the production, academic use, or storage of the Content. This release aligns with institutional risk management practices common in higher education and clinical simulation activities.
Governing Law and Venue
Which laws govern this agreement?
This Waiver and Consent Form is governed by the laws of the State of Minnesota. Any legal disputes arising under this agreement shall be addressed in the appropriate state or federal courts located in Minnesota.
NURS FPX 4015 Assessment 1 Waiver and Consent Form
Consent Confirmation
By signing this form, the Participant affirms that:
- They are at least 18 years of age.
- They have carefully read and understood all provisions outlined in this agreement.
- They voluntarily consent to participate under the terms described.
NURS FPX 4015 Assessment 1 Waiver and Consent Form
| Role | Signature | Date | Printed Name |
|---|---|---|---|
| Student | ________________________ | 24-02-2025 | ____________________ |
| Participant | ________________________ | 24-02-2025 | ____________________ |
References
American Nurses Association. (2023). Code of ethics for nurses with interpretive statements. ANA Publishing.
Capella University. (2024). Nursing program simulation and assessment guidelines. Capella University Academic Resources.