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

Institution: Capella University Course: NURS4015 or NURS-FPX4015

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

By providing this consent, I acknowledge and agree to the following terms and conditions for fair consideration:

Purpose of the Waiver

The purpose of this waiver is to clearly outline the intended use of all recorded materials and related information (hereafter referred to as “Content”) for educational purposes. These purposes include:

Demonstrating and evaluating nursing assessment skills and techniques for academic assessment.
Supporting the completion of course-required examinations, including the development of a SOAP (Subjective, Objective, Assessment, Plan) note.
Presenting simulated health information for practice assignments or classroom exercises.

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

Content

I grant permission for the Student to record video and collect information necessary to complete the SOAP note. The term “Content” encompasses:

The video recording, my image, voice, likeness, and appearance.
Any words or statements I provide during the demonstration.
Any health-related data collected in alignment with the educational purposes described above.

Disclosures

The information used in this simulation is strictly for educational purposes and does not replace medical evaluation, diagnosis, or treatment.

Neither the Student nor I am required to provide real medical history or sensitive personal health information.
Except for age and gender (which may be accurately reported), all other details may be hypothetical.
I acknowledge that certain objective measures, such as vital signs, may reflect actual data.

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

Use, reproduce, distribute, publish, display, and share the Content.
Disclose the Content to instructors, faculty, or staff for instructional or evaluative purposes.

I also waive the right to:

Inspect or approve the Content before its use.
Claim any damages or compensation related to the production, use, or modification of the Content.

Rights and Ownership

I recognize that Capella University retains exclusive ownership of all Content generated under this waiver. The Content will constitute the university’s sole intellectual property.

I release Capella University from all claims related to:

Use, creation, or ownership of the Content.
Publicity rights, privacy concerns, defamation, or any personal harm.

Waiver and Release

I release Capella University, 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 under this agreement will be resolved in Minnesota state or federal courts.

By signing below, I confirm that:

I am at least eighteen (18) years old.
I have read, understood, and agreed to all terms outlined in this Waiver and Consent Form.

Table 1

Signature and Agreement Details

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

References

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

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