The notice and consent form must include:
(1)A statement affirming that the resident consents to video monitoring and assumes full responsibility for implementing any restrictions imposed on the placement and use of the video monitoring device and on the dissemination and use of any data produced by the device;
(2)If the resident has a roommate, a statement affirming that the roommate, subject to any noted restrictions, consents to video monitoring by the resident and to the dissemination and use of any data produced by the device;
(3)A description of the video monitoring device, including the brand name and model number, and the installation and operating requirements;
(4)Restrictions that the resident or the roommate impose on the placement and use of the video monitoring device, inc
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The notice and consent form must include: (1) A statement affirming that the resident consents to video monitoring and assumes full responsibility for implementing any restrictions imposed on the placement and use of the video monitoring device and on the dissemination and use of any data produced by the device; (2) If the resident has a roommate, a statement affirming that the roommate, subject to any noted restrictions, consents to video monitoring by the resident and to the dissemination and use of any data produced by the device; (3) A description of the video monitoring device, including the brand name and model number, and the installation and operating requirements; (4) Restrictions that the resident or the roommate impose on the placement and use of the video monitoring device, including: (a) Prohibitions on video recording; (b) Prohibitions on broadcasting video recordings; (c) Requiring that the video monitoring device be turned off or blocked during an examination or procedure by a health care provider; (d) Requiring that the video monitoring device be turned off or blocked while dressing, bathing, or personal care is being performed; and (e) Requiring that the video monitoring device be turned off or blocked during a visit with an attorney, financial planner, intimate partner, ombudsman, spiritual adviser, or other visitor; (5) A statement of the circumstances under which a video recording may be disseminated; (6) A section for documenting the withdrawal of consent by the resident or a roommate; (7) The signature of the resident and the date of signing; and (8) If the resident has a roommate, the signature of the roommate and the date of signing. The resident or a roommate may amend the information contained in the notice and consent form. Any amendment must be dated, signed, and submitted to the facility. If the notice and consent form or an amendment to the form is signed by an authorized representative, it must include a physician’s statement verifying that the person, on whose behalf the authorized representative is acting, lacks decision-making capacity, and a copy of the guardianship order or power of attorney granting the authorized representative authority to consent to video monitoring. Upon receiving a completed notice and consent form, or any amendment to the form, the facility shall place the form in the resident’s file and provide a copy to the resident or an authorized representative of the resident, and to the resident's roommate or an authorized representative of the roommate. The notice and consent form, or an amendment thereto, is not effective until it has been received by the facility.