NURS FPX 4015 Assessment 1 Waiver and Consent Form

Grace J.
February 26, 2026February 26, 2026
BSN, NURS-FPX4015

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

This Waiver and Consent Form documents the voluntary agreement of ___________________ (“Participant”) to serve as a simulated patient in a recorded health assessment demonstration conducted by ___________________ (“Student”), a nursing learner enrolled at Capella University. By signing this form, the Participant confirms understanding of the scope, purpose, and legal implications of participation in this academic activity.

Purpose of the Waiver

What is the purpose of this waiver?

This waiver clarifies the educational intent and authorized use of all recorded materials and related information (collectively referred to as “Content”). The Content will be used exclusively for academic and instructional objectives within the nursing program.

Specifically, the recording and related materials will be used to:

Demonstrate and evaluate clinical nursing assessment competencies.
Facilitate completion of required coursework, including preparation of a SOAP (Subjective, Objective, Assessment, Plan) note.
Provide structured simulation data for academic exercises and skills validation.

The Participant acknowledges that the Content will not be subject to their review, alteration, or approval prior to its academic use.

Content Authorization

What constitutes “Content” under this agreement?

The Participant consents to the creation and collection of the following categories of Content:

Component	Description
Video Recording	Any digital recording capturing the Participant’s image, voice, likeness, or physical presentation.
Verbal Statements	All spoken responses, dialogue, or explanations provided during the simulation.
Health-Related Information	Data collected for educational demonstration purposes consistent with learning objectives.

The Content is limited to what is reasonably necessary to complete the required academic assessment.

Disclosures

Is this activity considered medical care?

No. This simulation is strictly educational in nature. It does not constitute medical advice, diagnosis, evaluation, or treatment.

Is real medical history required?

No. Neither the Student nor the Participant is obligated to disclose actual medical history or confidential personal health information. With the exception of age and gender, which may be represented accurately, all other case details may be fictional or adapted for academic purposes.

This approach aligns with nursing education standards emphasizing confidentiality, ethical practice, and simulated learning environments (American Nurses Association [ANA], 2023).

Voluntary Consent and Authorized Use

What rights are granted to Capella University?

By signing this form, the Participant voluntarily grants Capella University a perpetual, royalty-free license to:

Use, reproduce, distribute, publish, and display the Content.
Share the Content with faculty, instructors, staff, or evaluators for academic review.
Retain the Content as part of institutional educational records.

What rights are waived?

The Participant waives the right to:

Review or approve the Content prior to its use.
Receive financial compensation related to the creation or academic use of the Content.
Pursue claims for damages arising from authorized academic use of the Content.

Rights and Ownership

Who owns the recorded material?

All Content produced under this agreement remains the exclusive intellectual property of Capella University. The university retains full ownership, including rights to archival storage and academic dissemination.

What claims are released?

The Participant releases the university from claims related to:

Content creation, modification, or distribution.
Alleged violations of privacy or publicity rights.
Claims of defamation or reputational harm arising from authorized academic use.

Waiver and Release of Liability

The Participant formally releases Capella University, including its trustees, faculty, employees, students, contractors, and affiliated representatives, from liability, claims, or expenses that may arise in connection with the production, academic use, or storage of the Content.

This release reflects common institutional risk management practices in higher education settings involving simulated clinical instruction.

Governing Law and Venue

Which laws govern this agreement?

This Waiver and Consent Form is governed by the laws of the State of Minnesota. Any dispute arising under this agreement shall be resolved in the appropriate state or federal courts located in Minnesota.

Consent Confirmation

By signing below, the Participant affirms:

They are at least 18 years of age.
They have carefully reviewed and understood all provisions of this agreement.
They voluntarily consent to participate under the stated terms.