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”), willingly provide my consent to participate as a mock patient in a health assessment video demonstration, which will be conducted by ___________________ (“Student”), a nursing learner enrolled at Capella University.

For the acknowledgment of fair consideration, I fully and permanently agree to the following terms and conditions:

Purpose of the Waiver

The primary intention of this waiver is to clarify that the recorded materials and related data (hereafter referred to as “Content”) will solely serve educational functions. These include, but are not restricted to:

Demonstrating health assessment skills and techniques for academic evaluation.
Supporting the completion of a comprehensive examination and the development of a SOAP (Subjective, Objective, Assessment, Plan) note required in the course curriculum.
Presenting hypothetical health information for a simulated practice assignment.

I acknowledge and accept that I will not have the right to review or approve the Content before it is used by Capella University.

Content

I grant permission for video recording during the demonstration and for the collection of information needed to complete the SOAP note. The term “Content” refers to the recorded video, my image, voice, likeness, words, and appearance, as well as any health-related data collected by the Student in line with the Purpose.

Disclosures

The data used in this simulation is educational and does not substitute actual medical evaluation, diagnosis, or treatment. Both the Student and I are not required to share real medical history or sensitive personal health information. With the exception of age and gender (which may be used), other details can be hypothetical. However, I recognize that certain readings, such as vital signs, may reflect my actual health data.

I freely grant Capella University the perpetual and royalty-free right to use, reproduce, distribute, publish, display, and share the Content. The Content may be disclosed to instructors, faculty, or staff members of Capella University for evaluation and instructional purposes.

I waive my rights to:

Inspect or approve the Content prior to its use.
Make any claims for damages or compensation related to the production, use, or modification of the Content.

Rights and Ownership

I acknowledge that Capella University will maintain exclusive ownership of all Content generated through this waiver. The Content will be the sole intellectual property of Capella University.

I release the university from any claims associated with the use, ownership, or creation of the Content. This includes issues related to publicity rights, privacy, defamation, or any personal harm.

Waiver and Release

I hereby release and agree not to hold Capella University, its trustees, employees, students, agents, contractors, and affiliates responsible for any damages, claims, or costs arising from the production, distribution, or use of the Content.

Governing Law and Venue

This waiver is governed by the laws of the State of Minnesota, and any disputes related to the agreement will be resolved within Minnesota state or federal courts.

By signing, I confirm that I am at least eighteen (18) years old and that I have carefully read, comprehended, and agreed to the conditions stated 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. Minnesota Legislature. (2024). Consent and liability laws for educational purposes. State of Minnesota.