Consent for Invasive Procedures

Effective Date September 25, 2017

I understand that in my Pacific Lutheran University nursing education I will have the opportunity to practice specific invasive procedures on manikins and/or consenting nursing students. The invasive procedures that may be practiced on consenting nursing students are limited to intradermal, intramuscular, subcutaneous injections of normal saline, venipuncture and venipuncture with catheter insertion, and/or fingersticks using sterile equipment and appropriate infection control measures. I understand that a faculty member who is a registered nurse must be in attendance during any SoN lab sessions in which these procedures are practiced. I will not perform, nor allow to be performed on me, any of these procedures unless a nursing program faculty member is present.

I understand that receiving injections or venipuncture or fingersticks administered by other nursing students is strictly voluntary, and non-participation will not impact my grade. I understand that the possible risks of these procedures include localized pain, infection, minor bleeding, body fluid exposures, or damage to tissue or nerves.

I hereby release and agree to indemnify Pacific Lutheran University, its Regents, faculty, staff, and students of any and all liability, claims and causes of actions arising out of or in any way connected with any and all activity occurring in the SoN lab sessions where these procedures are being practiced.

I give my consent for nursing students to practice injections of sterile normal saline, fingersticks, venipunctures, and/or venipunctures with sterile catheter insertion on me.

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Student Signature                           Date

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Print Name

I decline to have nursing students practice injections of sterile normal saline, fingersticks, venipunctures, and/or venipunctures with sterile catheter insertion on me.

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Student Signature                           Date

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Print Name

NOTE: This form is to be signed and dated each semester. If the student wishes to change his/her consent at any time during the semester, a new form must be signed and dated.