NURS FPX 4015 Assessment 1

NURS FPX 4015 Assessment 1 Waiver and Consent Form

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”), willingly consent to take part 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 acknowledgment of valuable consideration received, I agree to the following terms outlined in this waiver:

Purpose of Participation

The primary aim of this agreement is to ensure that the recorded content is used solely for academic purposes. These purposes include but are not limited to:

1. Demonstrating health assessment skills and techniques for faculty evaluation.
2. Completing a comprehensive assessment using a SOAP (Subjective, Objective, Assessment, and Plan) note as required in the course.
3. Providing simulated patient information to support a clinical practice assignment.

I also acknowledge that I waive the right to preview or approve the final content prior to its use by Capella University.

Content and Recording Agreement

The term “Content” refers to all video recordings, likeness, images, voice, verbal communication, and data collected during the mock assessment. This includes the information used to complete the SOAP note. I grant permission for my participation to be recorded, acknowledging that such recordings will serve strictly for educational activities aligned with the course objectives.

Information Disclosure Policy

I understand that:

• All shared health-related data is for educational demonstration only and does not represent professional medical advice or a clinical diagnosis.
• The Participant is not required to provide actual medical history or private health information unless they choose to do so.
• Information such as age and gender may be shared, while other details can remain hypothetical for the simulation.
• Any vital signs or readings taken during the demonstration may reflect my actual health status.

Voluntary Consent and Content Usage

By agreeing to this waiver, I grant Capella University irrevocable rights to:

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

I understand that I waive the right to:

• Review or approve the Content before use.
• Pursue claims for damages related to alterations, editing, or reproduction of my recorded likeness or voice.

Rights and Ownership of Content

I acknowledge that Capella University retains full ownership of the Content. All recordings, data, and related materials created as part of this waiver are the sole property of the University.

By signing, I also release the University from:

• Any claims relating to ownership, creation, or use of the Content (e.g., privacy rights, defamation, or publicity concerns).
• Any potential injuries, damages, or costs associated with participation in this educational activity.

Waiver and Release of Liability

I voluntarily release and discharge Capella University, its trustees, faculty, students, employees, agents, and contractors from all liabilities, claims, damages, or legal actions arising from the production, distribution, or use of the Content. This waiver ensures I will not seek legal action related to my participation in the activity.

Governing Law and Jurisdiction

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

NURS FPX 4015 Assessment 1 Waiver and Consent Form

The undersigned confirm that they are above the age of 18, have read the conditions of this waiver, and fully understand the terms of participation.

Agreement Table

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

NURS FPX 4015 Assessment 1 Waiver and Consent Form