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 Information

Institution: Capella University
Course: NURS4015 or NURS-FPX4015

Participant Agreement

I, __________________ (“Participant”), willingly consent to take part as a mock patient in the health assessment video demonstration led by __________________ (“Student”), a nursing student at Capella University.

This consent is granted in exchange for educational value and acknowledgment of my voluntary participation. I understand and agree to the terms outlined below.

Purpose of the Video Demonstration

The primary goal of this activity is educational. The video and associated documentation (“Content”) will be used to:

Demonstrate nursing health assessment skills and techniques for academic evaluation.
Fulfill a course requirement by completing a subjective, objective, assessment, and plan (SOAP) note aligned with clinical practice standards.
Provide simulated health-related information for academic assignments, reinforcing real-world clinical practice scenarios.

The Participant understands that the Content will not be used for personal or commercial purposes, but solely for instructional and evaluative needs within Capella University.

Content Agreement

The Participant agrees to be video recorded, and consents to the Student gathering necessary data to prepare the SOAP note.

Definition of Content:
Content includes, but is not limited to:

Elements of Content	Description
Video Recording	Recorded demonstration featuring assessment techniques conducted by the Student.
Participant’s Involvement	Image, likeness, voice, and any verbal responses during the assessment.
Collected Information	Vital signs, hypothetical details, and any health-related data shared for educational purposes.

Disclosures and Limitations

The information provided in the Content is for demonstration only and does not serve as medical advice or a real diagnosis.
Neither the Student nor the Participant is required to disclose personal or sensitive health information.
With the exception of age and gender, all shared information can be fictionalized for the assignment.
Any actual vital signs recorded may reflect the true health status of the Participant.

Voluntary Consent and Use of Content

The Participant grants Capella University unrestricted, royalty-free, and irrevocable rights to use the Content strictly for academic purposes. This includes distribution, reproduction, publication, and use in course evaluation.

The Participant waives:

The right to preview or approve the Content before it is used.
The right to claim compensation or damages related to any alterations, distortions, or reproductions of the Content.

Rights and Ownership

All ownership and intellectual property rights of the Content belong exclusively to Capella University. The Participant acknowledges and consents that:

Capella University is the sole owner of all recordings and materials created.
No financial or personal claims may be made regarding the ownership or distribution of the Content.
The Participant releases Capella University from all liability connected to the creation, publication, or academic use of the Content.

Waiver and Release of Liability

The Participant fully releases and agrees not to hold Capella University, its faculty, students, staff, agents, or affiliates liable for any claims, damages, injuries, or expenses that may arise from the recording, use, or distribution of the Content.

Governing Law and Jurisdiction

This Waiver is legally governed by the State of Minnesota. Any disputes will be resolved within state or federal courts located in Minnesota.

Acknowledgment of Understanding

By signing this form, the Participant confirms that they are over 18 years of age and that they fully understand and voluntarily agree to the conditions stated in this Waiver.

Agreement and Signatures

Student:

Signature: ___________________ Date: _______
Printed Name: _________________

Participant:

Signature: ___________________ Date: _______
Printed Name: _________________

References

Capella University. (n.d.). Consent and waiver forms for academic purposes. Capella University Policy Office.

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