Student Name
Capella University
NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care
Prof. Name
Date
NURS FPX 4015 Assessment 1 Waiver and Consent Form
Waiver and Consent Form
This Waiver and Consent Form outlines the voluntary agreement of ___________________ (“Participant”) to take part as a simulated patient in a recorded health assessment activity conducted by ___________________ (“Student”), who is currently enrolled in a nursing program at Capella University. By signing this document, the Participant acknowledges a clear understanding of the purpose, procedures, and implications associated with this academic exercise. Participation is entirely voluntary, and the Participant may withdraw at any point without penalty or negative consequences.
Purpose of the Waiver
What is the purpose of this waiver?
The primary objective of this waiver is to define the academic nature of the activity while clarifying how all recorded materials and related data (collectively referred to as “Content”) will be utilized. The Content produced during this exercise is intended exclusively for educational and instructional use within the nursing program.
Specifically, the recorded materials and information will be used to:
- Demonstrate and evaluate clinical nursing competencies in a structured learning environment.
- Support completion of academic requirements, including the preparation of a SOAP (Subjective, Objective, Assessment, Plan) note.
- Provide standardized simulation data to facilitate learning, performance assessment, and reflective practice.
The Participant understands that they will not be permitted to review, edit, or approve the Content prior to its academic use. This policy ensures fairness, consistency, and integrity in student evaluation, aligning with professional standards in nursing education (American Nurses Association [ANA], 2023).
Content Authorization
What constitutes “Content” under this agreement?
The Participant consents to the creation and academic use of various forms of Content generated during the simulation. These components are summarized below:
| Component | Description |
|---|---|
| Video Recording | Digital recordings capturing physical appearance, voice, expressions, and actions during the simulation. |
| Verbal Statements | All spoken communication, including responses, explanations, and interactions. |
| Health-Related Information | Information shared for educational purposes that aligns with assessment objectives. |
All Content will be used strictly within the boundaries necessary to achieve the educational goals of the nursing assessment. Any use beyond these limits is strictly prohibited.
Disclosures
Is this activity considered medical care?
No, this activity does not involve actual healthcare services. It is a simulated educational exercise designed solely for instructional and evaluative purposes. No diagnosis, treatment, or medical advice is provided.
Is real medical history required?
No, Participants are not required to disclose real medical histories. They may provide fictional or generalized information, except for basic demographic details (such as age and gender) when necessary. This approach helps maintain confidentiality and upholds ethical standards in nursing education (ANA, 2023).
Voluntary Consent and Authorized Use
What rights are granted to Capella University?
By consenting to participate, the Participant grants Capella University a perpetual, royalty-free license to:
- Use, reproduce, and distribute the Content for academic purposes.
- Share the Content with faculty, evaluators, and relevant academic personnel.
- Retain the Content as part of institutional and educational records.
NURS FPX 4015 Assessment 1 Waiver and Consent Form
What rights are waived?
The Participant agrees to waive the following rights:
- The right to review or approve the Content prior to its academic use.
- The right to receive financial compensation related to the Content.
- The right to initiate legal claims related to the authorized academic use of the Content.
Rights and Ownership
Who owns the recorded material?
All Content generated during this activity is the exclusive intellectual property of Capella University. The institution retains full rights to store, use, distribute, and archive the material for educational and evaluative purposes.
What claims are released?
The Participant releases Capella University from any claims related to:
- The creation, modification, or academic use of the Content.
- Any perceived violation of privacy or publicity rights.
- Claims involving defamation, reputational harm, or similar concerns arising from authorized use.
Waiver and Release of Liability
The Participant agrees to release Capella University, including its faculty, staff, students, contractors, and affiliated representatives, from any legal or financial responsibility associated with the creation, use, or storage of the Content. This clause reflects standard risk management practices commonly applied in higher education and clinical simulation settings.
Governing Law and Venue
Which laws govern this agreement?
This agreement is governed by the laws of the State of Minnesota. Any legal disputes arising from this waiver will be addressed in the appropriate state or federal courts located within Minnesota.
NURS FPX 4015 Assessment 1 Waiver and Consent Form
Consent Confirmation
By signing below, the Participant confirms that:
- They are at least 18 years of age.
- They have carefully read and understood all terms outlined in this document.
- They voluntarily agree to participate under the specified conditions.
NURS FPX 4015 Assessment 1 Waiver and Consent Form
| Role | Signature | Date | Printed Name |
|---|---|---|---|
| Student | ________________________ | 24-02-2025 | ____________________ |
| Participant | ________________________ | 24-02-2025 | ____________________ |
