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

Waiver and Consent Form

Institution: Capella University
Course: NURS4015 or NURS-FPX4015

I, ___________________ (“Participant”), willingly agree to take part as a simulated patient in a health assessment video activity conducted by ___________________ (“Student”), a nursing learner at Capella University.

This form serves as an acknowledgment that I fully understand the purpose, nature, and rights associated with this activity. For recognition of participation, I irrevocably consent to the following terms:

Purpose

The primary goal of this activity is strictly educational. The recording and related materials may be used for:

1. Demonstrating health assessment skills for academic review and evaluation.

2. Completing a comprehensive assessment, including a Subjective, Objective, Assessment, and Plan (SOAP) note, as outlined in the course curriculum.

3. Simulating clinical practice scenarios through hypothetical health data to strengthen nursing competency.

I acknowledge that this activity is not a medical consultation and I waive my right to preview or approve the final recording before its academic use.

Content

The term “Content” refers to:

• The recorded video demonstration of the health assessment.

• My voice, image, appearance, likeness, and participation during the activity.

• Any details gathered by the student to create the SOAP note.

I understand that the recording will only be used for course-related educational objectives and no other professional or commercial purposes.

Disclosures

• All information provided during this activity is for simulation purposes only.

• Neither the student nor the participant is required to disclose actual health history unless they choose to do so.

• Information such as name, identifiers, or personal details may be fictional.

• Vital signs or physical assessments taken during the session may reflect my actual health readings.

NURS FPX 4015 Assessment 1 Waiver and Consent Form

Voluntary Consent and Use

I voluntarily allow Capella University unrestricted, royalty-free rights to:

• Use, display, distribute, reproduce, and share the recording strictly for academic evaluation.

• Share the content with the instructor and, if necessary, other faculty members for assessment.

I waive the right to demand compensation, claim damages, or restrict any technical modifications (such as blurring or editing) to the recording.

Rights and Ownership

Capella University will retain complete ownership of the recorded material. I agree that:

• All intellectual property rights belong exclusively to the institution.

• I release the University from any claims related to privacy, publicity, or misrepresentation.

• The University cannot be held liable for injuries, costs, or damages resulting from this academic exercise.

Waiver and Release

I fully release and hold harmless Capella University, including its faculty, staff, contractors, students, and representatives, from all claims or liabilities connected to the recording. This includes any potential harm, damages, or legal disputes related to the production or academic use of the Content.

Governing Law and Venue

This agreement follows the legal framework of the State of Minnesota. Any legal proceedings or disputes will be resolved in Minnesota’s state or federal courts.

Acknowledgment of Understanding

By signing, I affirm that I am at least 18 years of age and have read, understood, and accepted the conditions outlined in this waiver.

Table: Consent and Agreement Details

Role	Signature	Date	Printed Name
Student	______________	________	________________
Participant	______________	________	________________

References

Capella University. (n.d.). Nursing course guidelines and consent forms. Capella University.

Minnesota Office of the Revisor of Statutes. (2023). Minnesota Statutes governing contracts and consent. https://www.revisor.mn.gov/statutes/

NURS FPX 4015 Assessment 1 Waiver and Consent Form

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