NURS FPX 4015 Assessment 1 Waiver and Consent Form

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

Institution: Capella University

Course: NURS4015 or NURS-FPX4015

I, ___________________  (“Participant”), hereby voluntarily agree to participate as a mock patient in the health assessment video demonstration to be conducted by ______________  (“Student”), a nursing student student at Capella University.

For good and valuable consideration, receipt of which is hereby acknowledged, I hereby irrevocably and perpetually agree to the following:

 

1. Purpose: I understand that the Content (defined below) will be used only for educational purposes, which may include, but are not limited to, the following: (i) to demonstrate health assessment techniques and skills for academic evaluation; (ii) to complete an academic comprehensive examination with an accompanying subjective, objective, assessment, and plan (SOAP) note for clinical practice (as more particularly described in the Course curriculum); and (iii) to provide hypothetical health information for a simulated clinical practice assignment (collectively, the “Purpose”). I waive the right to inspect or approve the Content prior to its use by Capella University.
2. Content: I consent to being video recorded for production of the Content and to Student collecting information to complete the accompanying SOAP note. “Content,” as used in this Waiver, is defined as a recorded video that is created for anything related to the Purpose, including any information or content that is conveyed in such recorded video and my image, likeness, appearance, words and voice as conveyed in such recorded video, as well as all information collected by Student to complete the accompanying SOAP note.  
3. Disclosures: I understand that any information included in the Content is for demonstration purposes only and does not constitute actual medical advice or diagnosis. Further, I understand that the Student and Participant are not required to disclose or represent actual medical history, status, or personal health information as part of the Content. Other than age and gender, any information provided by the Participant, including personal identifiers, can be hypothetical for the simulated assignment. However, I understand that certain vital signs or other health readings taken during the simulation may reflect my actual health information.
4. Voluntary Consent/Use: I voluntarily grant to Capella University the royalty-free absolute and irrevocable right and unrestricted permission to use the Content on behalf of Capella University and to disclose, distribute, display, reproduce, publish and exploit the Content in connection with such use. I understand that the Content will be shared with the course instructor, and possibly other Capella University faculty or staff, for educational and evaluation purposes only. I waive the right to (i) inspect or approve the Content prior to its use by Capella University and (ii) assert any claim to damages or other compensation arising out of any use of any Content, including without limitation any blurring, alteration, distortion, illusionary effect, or faulty reproduction of my image, likeness, appearance, words or voice.
5. Rights and Ownership: I agree that Capella University shall have the full, exclusive, and complete ownership of the Content produced pursuant to this Waiver, which shall be deemed the sole property of Capella University, all of which ownership and other rights I hereby grant to Capella University for good and sufficient consideration.  I release Capella University from (i) any and all claims that I may have arising out of or related to the ownership, creation or use of any Content, including without limitation all claims based on or related to any right of publicity or privacy or defamation, and (ii) any and all injuries, losses, costs, damages and expenses that I may incur as a result of the creation or use of the Content.
6. Waiver/Release: I release, waive, forever discharge, hold harmless and covenant not to sue Capella University and its affiliates, and its and their trustees, employees, students, contractors, agents or representatives from and against any and all liability for any harm, injury, damage, claims, actions, causes of action, costs, demands, and expenses of any nature whatsoever relating to the making, showing, distribution or use of Content. 
7. Governing Law and Venue: This Waiver is governed by the laws of the State of Minnesota. Accordingly, the state or federal courts located in the State of Minnesota are the agreed-upon forum for the resolution of all disputes arising under this Waiver. 

NURS FPX 4015 Assessment 1 Waiver and Consent Form

By signing below, I represent that I am over the age of eighteen (18) years and that I have read and understood the terms and conditions outlined in this Waiver. 

Agreed and Accepted: 

Student: 

Signature: ____________________________ Date: ____24-02-2025____

Printed Name: ____________________________

 

Participant: 

Signature: ____________________________ Date: _____24-02-2025___

Printed Name: ____________________________