College of Nursing

Release Form

 

UMSL College of Nursing Simulation Release
Confidentiality Statement / Photography Release Form

During your participation in a simulated clinical experience at the College of Nursing Skills/Simulation Center (NSC), you will be both an active participant in simulated scenarios and an observer.

The objective of the simulation experience is to provide the undergraduate nursing student the opportunity to provide real life nursing care (assessments and interventions) in a real life patient care situation that allows the student to make mistakes with no harm to actual patients.  The simulation experience can occur as an individual or group experience.  By signing this agreement, you agree to maintain strict confidentiality regarding both performance and the performance of others, whether seen in real time, on video or otherwise communicated to you. Failure to maintain confidentiality may result in unwarranted and unfair defamation of character of the participants.You will be discussing the scenarios during debriefing, but we believe that, “All that takes place in the simulation environment – stays in the simulation
environment!” In order to maintain optimal simulation experiences for the other learners who will be following you in the center, you are to maintain strict confidentiality regarding the specific scenarios, as well as what happened during the simulation experience. A breach of confidentiality may result in consequences including a failing grade for that experience that may potentially result in course failure.

______I agree to maintain strict confidentiality about the details of the scenarios,
participants, and performance of any participant(s).

______I authorize the College of Nursing faculty and/or staff to video record my performance during simulation experience.

______I authorize the College of Nursing faculty/staff  to use the video recording(s) for purposes including, but not limited to: debriefing, faculty review, educational research,
public relations, , and/or fund raising activities.

____________________________________________                                          

Student Signature                                                                          Date     

 

06/09 Saleska