NURS FPX 4015 Assessment 1 Waiver and Consent Form

Grace J.
March 18, 2026March 18, 2026
BSN, Capella University, NURSFPX4015

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 activity conducted by ___________________ (“Student”), who is currently enrolled in a nursing program at Capella University. By signing this form, the Participant confirms that they fully understand the purpose, procedures, and implications of participating in this academic exercise. Participation is entirely optional, and the Participant retains the right to withdraw at any stage without any consequences.

Purpose of the Waiver

What is the purpose of this waiver?

The purpose of this waiver is to clearly define the academic intent of the activity while outlining how any recorded materials and associated information (referred to as “Content”) will be used. The Content generated during this exercise is intended solely for educational and instructional purposes within the nursing program.

The recorded materials and data will specifically be utilized to:

Demonstrate and assess clinical nursing competencies.
Assist in completing coursework requirements, including the development of a SOAP (Subjective, Objective, Assessment, Plan) note.
Provide structured simulation data for learning activities, performance evaluation, and reflective practice.

The Participant understands that they will not have the opportunity to review, edit, or approve the Content before its academic use. This ensures fairness and integrity in evaluation and aligns with established standards in nursing education (American Nurses Association [ANA], 2023).

Content Authorization

What constitutes “Content” under this agreement?

The Participant agrees to the creation and academic use of various forms of Content generated during the simulation. These elements are outlined below:

Component	Description
Video Recording	Digital recordings capturing the Participant’s appearance, voice, facial expressions, and physical actions during the simulation.
Verbal Statements	Any spoken communication, including responses, explanations, or interactions provided by the Participant.
Health-Related Information	Information collected for educational purposes that aligns with the learning objectives of the assessment.

The use of Content is strictly limited to what is necessary to achieve the academic goals of the nursing assessment. Any use beyond these parameters is not permitted.

Disclosures

Is this activity considered medical care?

No, this activity does not involve actual medical care. It is strictly an educational simulation designed for instructional and assessment purposes. No diagnosis, treatment, or medical advice is provided during this exercise.

Is real medical history required?

No, the disclosure of real medical history is not required. Participants may use fictional or generalized information, except for basic demographic details such as age and gender if needed. This approach ensures confidentiality and supports ethical practices in nursing education (ANA, 2023).

Voluntary Consent and Authorized Use

What rights are granted to Capella University?

By agreeing to participate, the Participant grants Capella University a perpetual, royalty-free license to:

Use, reproduce, and distribute the Content.
Share the Content with faculty members, evaluators, and academic staff for review purposes.
Retain the Content as part of educational and institutional records.

What rights are waived?

The Participant agrees to waive the following rights:

The right to review or approve the Content before it is used academically.
The right to receive any financial compensation related to the Content.
The right to pursue legal claims arising from the authorized academic use of the Content.

Rights and Ownership

Who owns the recorded material?

All Content produced during this activity is the exclusive intellectual property of Capella University. The institution retains full ownership, including the right to archive, distribute, and use the material for future educational or evaluative purposes.

What claims are released?

The Participant releases Capella University from any claims related to:

The creation, modification, or academic use of the Content.
Any alleged infringement of privacy or publicity rights.
Claims of defamation, reputational harm, or related concerns resulting from authorized use.

Waiver and Release of Liability

The Participant formally releases Capella University, along with its faculty, staff, students, contractors, and affiliated representatives, from any legal or financial liability associated with the creation, use, or storage of the Content. This provision reflects standard risk management practices within higher education and clinical simulation environments.

Governing Law and Venue

Which laws govern this agreement?

This agreement is governed by the laws of the State of Minnesota. Any disputes arising from this waiver will be resolved in the appropriate state or federal courts located within Minnesota.