Confidentiality Agreement & Consent to Video Recording

  • During your participation in a simulated clinical experiance (SCE) at the Father Muller Simulation & Skills Centre (FMSSC), you will be both an active participant in simulated scenarios and an observer.
  • The objective of the SCE program is to educate pre-licensed and licensed health care practitioners to better assess and improve their performance in evolving health care situations, ulimately leading to patient safety.
  • By signing this agreement, you agree to maintain strict confidentiality regarding the performance, 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 safe simulation environment!" Due to copyrights, and 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 loss of privileges at FMSSC.
  • ______I agree to maintain strict confidentiality about the details of the scenarios, participants, and performance of any paticipant(s).
  • ______I authorize the FMSSC staff to video record my performance during Clinical Simulation Experience(CSE).
  • ______I authorize the FMSSC staff to use the video recording(s) for purposes including, but not limited to: Debriefing, Faculty Review, Educational, Research, Public Relations, Advertisement, Promotional, and/or Fund raising activities.
  • Every learner in FMSSC will read and sign this simulation confidentiality agreement and consent for Video/Audio recording at the beginning of each course prior to utilizing the simulation lab and equipment. This form will be on file in the simulation lab.