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

I, ___________________ (“Participant”), voluntarily agree to participate as a mock patient in a health assessment video demonstration conducted by ___________________ (“Student”), who is a nursing learner enrolled at Capella University. By signing this document, I acknowledge and accept the terms outlined below.

Purpose of the Waiver

The purpose of this waiver is to clarify the intended educational use of all recorded materials and information (hereafter referred to as “Content”).

1. Demonstrate and evaluate nursing assessment skills and techniques for academic purposes.
2. Support completion of course-required assignments, including the development of a SOAP (Subjective, Objective, Assessment, Plan) note.
3. Provide simulated patient information for classroom exercises and practice assignments.

I understand that I will not have the right to review, modify, or approve the Content prior to its educational use by Capella University.

Content

I provide consent for the Student to record video and collect information necessary for completing the SOAP note. “Content” includes:

Component	Description
Video Recording	Any video capturing my image, voice, likeness, or overall appearance.
Verbal Statements	Any words, statements, or responses I provide during the demonstration.
Health Data	Any health-related information gathered in alignment with the educational objectives above.

Disclosures

• The simulation and related information are strictly for educational purposes and are not intended to replace medical evaluation, diagnosis, or treatment.
• Neither the Student nor I am required to provide actual medical history or sensitive personal health information.
• With the exception of age and gender, which may be reported accurately, all other details may be hypothetical.

Voluntary Consent and Use of Content

I voluntarily grant Capella University perpetual, royalty-free rights to:

• Use, reproduce, distribute, publish, display, and share the Content.
• Share the Content with instructors, faculty, or staff for instructional or evaluative purposes.

I also waive the following rights:

• To review or approve the Content before it is used.
• To claim any compensation, damages, or claims related to the creation, use, or modification of the Content.

Rights and Ownership

I understand that Capella University retains full ownership of all Content created under this waiver. The Content will remain the university’s intellectual property.

I release Capella University from any claims related to:

• The use, creation, or ownership of the Content.
• Publicity rights, privacy concerns, defamation, or personal harm related to participation.

Waiver and Release

I hereby release Capella University, including its trustees, employees, students, agents, contractors, and affiliates, from any liability, claims, or costs that may arise from the production, distribution, or use of the Content.

Governing Law and Venue

This Waiver and Consent Form is governed by the laws of the State of Minnesota. Any disputes arising from this agreement will be resolved in Minnesota state or federal courts.

Consent Confirmation

By signing below, I confirm:

• I am 18 years of age or older.
• I have read, understood, and agree to all terms outlined in this Waiver and Consent Form.

NURS FPX 4015 Assessment 1 Waiver and Consent Form

Signature and Agreement Details

Role	Signature	Date	Printed Name
Student	__________________________	24-02-2025	_____________________
Participant	__________________________	24-02-2025	_____________________

References

American Nurses Association. (2023). Consent, privacy, and confidentiality in nursing education. ANA Publications.

Capella University. (2025). Health assessment consent and waiver guidelines. Capella University.

Minnesota Legislature. (2024). Consent and liability laws for educational purposes. State of Minnesota.

NURS FPX 4015 Assessment 1 Waiver and Consent Form