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The UAB Office of Interprofessional Simulation looks forward to your upcoming participation in simulation activity.  We ask for all of our participants to do the following three things prior to your first simulation:

1. Watch this video, An Introduction to Healthcare Simulation: https://youtu.be/S4SGEimGU-c

2. Review the following consent agreements.

3. Acknowledge that you have reviewed the consent, media release, and safety resources document and submit the form.

Consent to Photograph, Video, or Audio Record

The participant does hereby agree and authorize UAB Office of Interprofessional Simulation and all respective employees, agents, directors, and trustees, hereafter known as “OIPS” to photograph, video record, and/or audio record their participation in simulation activities for the purposes of education, research, medical journal/publication, and/or marketing by OIPS and related UAB organizations.  Uses for photos/recordings may include but are not limited to: news releases, website content, printed marketing brochures, training/educational material, or other authorized forms of organizational communication (internal or public) without compensation of any kind. Identification of participant will be limited to role only (e.g., medical student, nurse, etc.); participants will not be identified by name.

The participant does hereby release and relinquish all rights and privileges to all aforementioned negative(s), print(s), audio recording(s) and/or video recording(s) while relinquishing all current and future rights and interests for the purposes contemplated herein.  This release shall be binding on the participant’s heirs and next of kin.

Simulation Confidentiality Agreement

Simulation activities at the University of Alabama at Birmingham (UAB) and/or Children’s of Alabama (COA) include simulated clinical scenarios, simulated task training, standardized patient scenarios, debriefings, and/or discussions.

All simulation activities at UAB and/or COA are considered confidential, whether electronic, written, verbal, observed or overheard, and may not be disclosed or discussed outside of the simulation environment. Any participants (e.g., students, learners, educators, instructors, faculty, staff or observers) in simulation activities at UAB and/or COA are expected to maintain confidentiality.  Any sharing, posting to social media, discussion, recording, reproducing, revealing or disclosure of simulation activity or performance is a violation of policy and may be grounds for disciplinary and/or legal action.

Participants are obligated to report any violations of confidentiality to the Office of Interprofessional Simulation at simulation@uab.edu.

Your acknowledgement below indicates that you have read, consent to, and fully understand the implications of this agreement, and agree to maintain the strictest confidentiality about simulation activities in which you participate and/or observe.  Furthermore, you understand a violation of confidentiality is strictly prohibited and serious consequences will occur if you violate the agreement.

Safety Resources

Physical and psychological safety are important to us. Click here to view the Safety Resources Document

Participant First Name(*)

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Participant Last Name(*)

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BlazerID (if applicable)

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Email Address(*)

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Role(*)

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Academic Program (for students only)














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I have read, understood, and agree to the media consent form, as presented above.(*)


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I have read, understood, and agree to the confidentiality agreement, as presented above.(*)


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I have read and understood the Safety Resources Document as presented above.(*)


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(*)

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