Healthcare Surgical Training Suite

HEALTHCARE SURGICAL TRAINING SUITE — PARTICIPANT ACKNOWLEDGMENT & AUTHORIZATION

Facility and Session

Facility Name:

Suite/Room Location:    Date of Session:    Time:

Participant Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History — Relevant to Participation

Training Session Details

Select training elements to be performed (check all that apply):

Simulation lab (mannequin/simulators)    Laparoscopic/robotic simulation    Endoscopic procedures    Cadaver laboratory    Live tissue/animal lab   

Mandatory Trainings & Compliance

Prior to participation I confirm the following trainings are completed and current:

PPE and sterile technique training completed    Bloodborne pathogens training completed    HIPAA/privacy training completed

Risks, Benefits, and Conditions of Participation

I acknowledge that participation in surgical training activities involves inherent risks, including exposure to sharps, potential exposure to bloodborne pathogens, chemical disinfectants, and other hazards associated with surgical instruments and simulation materials. I understand that direct patient care will not be performed without separate authorization.

Benefits of participation include supervised technical instruction, procedural practice, and skill acquisition. The facility and instructors will take reasonable measures to minimize risk; however, I accept responsibility to follow all safety protocols and to immediately report unsafe conditions.

Authorization to Record and Use Media

I authorize the recording, photography, or capture of procedure and instructional activities in which I participate for educational and quality improvement purposes. I understand recordings may include my voice and image and may be used in internal training, presentations, and publications. I understand that identifying patient information must never be recorded or disclosed and that recordings involving patients require separate patient authorization.

Consent to record for educational purposes:    Yes    No

Confidentiality and Protected Health Information

I acknowledge the obligation to protect confidential information and any protected health information (PHI) encountered during training. I will not access, use, or disclose PHI except as expressly permitted in connection with authorized training activities. Unauthorized recording, copying, or removal of clinical records or photographs that contain identifying information is strictly prohibited and may result in disciplinary action or legal liability.

Assumption of Risk; Release and Indemnification

By signing below I voluntarily assume all risks associated with participation in the surgical training session, foreseeable and unforeseeable, including injury or illness. I release the facility, its instructors, agents, and sponsoring organization from liability for injury, loss, or damage arising from ordinary negligence in connection with training activities, to the fullest extent permitted by law.

I agree to indemnify and hold harmless the facility and its personnel from any claims, liabilities, costs, or damages arising out of my negligent or willful misconduct during participation.

Authorization, Expiration, and Revocation

I authorize participation under the terms set forth in this document. This authorization will remain in effect until: unless earlier revoked in writing. Revocation will not apply to actions taken in reliance on this authorization prior to receipt of revocation.

Acknowledgments (Initials)

By initialing each line I certify understanding and acceptance of the terms below.

Infection control and sharps safety protocols reviewed:

HIPAA and confidentiality obligations reviewed:

I will comply with PPE requirements at all times in the suite:

Acknowledgment and Signature

I certify that the information I have provided is true and complete to the best of my knowledge. I have read and understand the risks, responsibilities, and conditions set forth above. My signature below indicates informed consent to participate under these terms and authorization for use of non-identifying media for educational purposes as indicated.

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