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, Lisa Smith (“Participant”), voluntarily agree to take part as a mock patient in a health assessment video demonstration conducted by Brianna (“Student”), a nursing learner at Capella University. By signing this form, I acknowledge that I understand and accept the terms below.

Purpose of Participation

I understand that the recorded content will be used exclusively for educational objectives. These include:

Demonstrating health assessment techniques and clinical skills for academic evaluation.
Completing a comprehensive examination supported by a Subjective, Objective, Assessment, and Plan (SOAP) note, as required in the course curriculum.
Providing hypothetical health data for a simulated clinical assignment.

I acknowledge that I waive the right to review or approve the material prior to its use by Capella University.

Content Agreement

I consent to being video-recorded for the development of course-related materials. The “Content” includes my image, voice, likeness, words, and appearance, as captured in the recording, as well as any information I provide to assist the Student in completing the SOAP note.

Disclosures

I understand that:

The information captured is solely for demonstration and does not constitute professional medical advice or diagnosis.
Neither the Student nor the Participant is required to share actual medical history or private health details.
Except for general demographic data (such as age and gender), personal identifiers may be fictitious for the purpose of the assignment.
Certain vital signs or simulated health readings may reflect my actual health information.

I voluntarily grant Capella University full, royalty-free, and irrevocable rights to use the Content for educational purposes. This includes, but is not limited to, sharing with the course instructor, relevant faculty, or staff.

I further waive the right to:

Inspect or approve the Content prior to its use.
Make claims for damages or compensation related to the use of the Content, including alterations or modifications of my likeness, voice, or appearance.

Rights and Ownership

I acknowledge that Capella University will retain full and exclusive ownership of all Content created under this agreement. The material will be considered the property of the University.

I hereby release Capella University from:

Any claims related to ownership, creation, or use of the Content.
Legal claims involving publicity rights, privacy rights, defamation, or damages.
Any injuries, losses, or expenses that may arise due to the creation or academic use of the Content.

Waiver and Release

I fully release and agree not to pursue legal claims against Capella University, its affiliates, employees, contractors, students, or representatives concerning the production, sharing, or use of the Content.

Governing Law and Venue

This Waiver shall be governed by the laws of the State of Minnesota, and any disputes will be resolved exclusively in Minnesota state or federal courts.

By signing below, I confirm that I am at least 18 years of age, that I have carefully read and understood this Waiver, and that I voluntarily agree to the terms stated herein.

Table: Signatures and Acknowledgment

Role	Name	Signature	Date
Student	Brianna	Brianna (signed)	24-02-2025
Participant	Lisa Smith	Lisa Smith (signed)	24-02-2025

References

Capella University. (2023). Capella University Nursing Handbook. Capella University Press. American Nurses Association. (2021). Code of ethics for nurses with interpretive statements (4th ed.). ANA Publishing. Minnesota Office of the Revisor of Statutes. (2024). Minnesota statutes on contracts and consent. https://www.revisor.mn.gov