Name
Capella University
NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care
Prof. Name
Date
This Waiver and Consent Form documents the voluntary agreement of ___________________ (“Participant”) to participate 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 their understanding of the purpose, scope, and legal implications of engaging in this academic activity.
The primary purpose of this waiver is to define the educational objectives and authorized use of all materials collected during the simulation, collectively referred to as “Content.” The Content will be utilized exclusively for instructional and academic purposes within the nursing program.
Specifically, the recorded materials and related data will be used to:
Demonstrate and evaluate clinical nursing assessment skills.
Support the completion of required coursework, including the preparation of a SOAP (Subjective, Objective, Assessment, Plan) note.
Provide structured simulation data for academic exercises and skills validation.
The Participant acknowledges that they will not have the right to review, modify, or approve the Content prior to its academic use.
The Participant provides consent for 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, explanations, or dialogue provided during the simulation. |
| Health-Related Information | Data collected specifically for educational demonstration purposes, consistent with learning objectives. |
The Content is limited to information reasonably necessary to achieve the academic goals of the simulation.
No. This simulation is strictly an educational exercise and does not constitute medical advice, diagnosis, evaluation, or treatment.
No. Neither the Student nor the Participant is obligated to disclose actual medical history or personal health information. Case details may be adapted or fictionalized for academic purposes, except for age and gender, which may be represented accurately.
This approach is consistent with nursing education standards that emphasize ethical practice, confidentiality, and safe simulated learning environments (American Nurses Association [ANA], 2023).
By signing this agreement, the Participant voluntarily grants Capella University a perpetual, royalty-free license to:
Use, reproduce, distribute, publish, and display the Content for academic purposes.
Share the Content with faculty, instructors, staff, or evaluators for educational review.
Retain the Content as part of institutional educational records.
The Participant acknowledges and waives the following rights:
The ability to review or approve the Content before its academic use.
Any entitlement to financial compensation related to the creation or academic use of the Content.
The ability to pursue claims for damages arising from the authorized academic use of the Content.
All Content produced under this agreement is the exclusive intellectual property of Capella University. The university retains full ownership, including rights for archival storage, academic use, and future educational dissemination.
The Participant releases Capella University from any claims related to:
Creation, modification, or distribution of the Content.
Alleged violations of privacy, publicity rights, or confidentiality.
Allegations of defamation or reputational harm arising from authorized academic use.
The Participant formally releases Capella University, including its trustees, faculty, employees, students, contractors, and affiliated representatives, from any liability, claims, or expenses that may arise in connection with the production, academic use, or storage of the Content.
This release aligns with standard institutional risk management practices in higher education, particularly those involving simulated clinical instruction.
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 the appropriate state or federal courts located in Minnesota.
By signing below, the Participant affirms that:
They are at least 18 years of age.
They have carefully read and understood all provisions of this agreement.
They voluntarily consent to participate under the stated terms.
| Role | Signature | Date | Printed Name |
|---|---|---|---|
| Student | ________________________ | 24-02-2025 | ___________________ |
| Participant | ________________________ | 24-02-2025 | ___________________ |
