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 take part as a mock patient in a health assessment video demonstration to be conducted by __________________ (“Student”), a nursing student at Capella University.

For the purpose of clarity and record, I acknowledge and accept the following terms:

Purpose of Participation

I understand that the recorded material (hereafter referred to as Content) will be used strictly for academic and instructional purposes. This may include:

1. Demonstrating health assessment procedures and skills for academic evaluation.
2. Completing a comprehensive assessment, which involves preparing a Subjective, Objective, Assessment, and Plan (SOAP) note in alignment with course requirements.
3. Providing simulated health data as part of a hypothetical clinical practice scenario.

I acknowledge that the Content is not intended for public distribution and is confined to Capella University’s academic use. I also waive the right to review or approve the Content before its use.

Content Agreement

I give consent to being video recorded for the development of the Content. This includes allowing the Student to gather information necessary to complete the SOAP note. The Content includes:

• My image, appearance, voice, and words as captured in the recorded video.
• Any data provided during the simulation, whether real or hypothetical.
• Any information shared by the Student to complete the SOAP note.

Disclosures and Clarifications

I recognize that the information shared in the Content is for training purposes only and does not represent actual medical advice, treatment, or diagnosis. Neither the Student nor I are required to share genuine medical history or health conditions.

The only required identifiers for the demonstration may include age and gender. Other personal details or medical history may be fabricated for the purposes of the exercise. However, if actual health readings (such as vital signs) are recorded during the simulation, they may reflect my real health status.

Voluntary Consent and Use

I voluntarily grant Capella University full, royalty-free, and irrevocable rights to use the Content for academic and evaluative purposes. This includes distribution to faculty or staff for grading, feedback, or instructional use.

I further acknowledge that:

• I waive any right to preview the Content before it is used.
• I will not claim damages or request compensation for the use, editing, or reproduction of the Content.
• I understand that modifications (e.g., editing, distortion, or visual effects) may occur without affecting the validity of this agreement.

Rights and Ownership

I acknowledge that Capella University holds complete ownership of the Content created under this agreement. The university has the right to use, reproduce, and store the Content as academic property.

I hereby release the University from any claims relating to:

• Privacy violations, publicity rights, or defamation.
• Injuries or losses that may result from participation in the demonstration.

Waiver and Release of Liability

I fully release and discharge Capella University, its faculty, students, staff, contractors, and affiliates from any legal claims or liabilities connected with the creation, display, or academic use of the Content.

This includes, but is not limited to:

• Physical or emotional harm,
• Misuse of Content, or
• Any costs or damages arising from participation.

Governing Law

This agreement shall be governed by the laws of the State of Minnesota. Any legal disputes related to this Waiver shall be resolved exclusively in the state or federal courts of Minnesota.

Acknowledgment

By signing below, I confirm that I am over the age of eighteen (18) and that I have carefully read, understood, and accepted the terms of this agreement.

Agreement Table

References

Capella University. (2023). Health assessment simulation guidelines. Capella University Academic Resources.

American Nurses Association. (2021). Code of ethics for nurses with interpretive statements (4th ed.). ANA Publishing.

NURS FPX 4015 Assessment 1 Waiver and Consent Form

Pozgar, G. D. (2022). Legal and ethical issues for health professionals (6th ed.). Jones & Bartlett Learning.