d) The completed notification and consent form must include, at minimum, the following information:

1. 1) The resident's signed consent to electronic monitoring or the signature of the person consenting on behalf of the resident in accordance with Section 15 of the Act and Section 389.115. If a person other than the resident signs the consent form, the form must document the following:

   1. A) The date the resident was asked if he or she wants authorized electronic monitoring to be conducted in accordance with the Act and this Part;

C) An acknowledgement that the resident did not affirmatively object.

1. 2) The resident's roommate's signed consent or the signature of the person consenting on behalf of the resident's roommate in accordance with Section 15 of the Act and Section 389.120, if applicable, and any conditions placed on the roommate's consent. If a person other than the resident's roommate signs the consent form, the form must document the following:

   1. A) The date the roommate was asked if he or she wants authorized electronic monitoring to be conducted in accordance with the Act and this Part;

B) Who was present when the roommate was asked; and

1. C) An acknowledgement that the roommate did not affirmatively object.

5) The proposed date of installation for scheduling purposes;

1. 6) A copy of any contract for maintenance of the electronic monitoring device by a commercial entity;
2. 7) A list of standard conditions or restrictions that the resident or a roommate may elect to place on use of the electronic monitoring device, including, but not limited to:
3. A) Prohibiting audio recording;

4. B) Prohibiting broadcasting of audio or video;

   1. C) Turning off the electronic monitoring device or blocking the visual recording component of the electronic monitoring device for the duration of an exam or procedure by a health care professional;
   2. D) Turning off the electronic monitoring device or blocking the visual recording component of the electronic monitoring device while dressing or bathing is performed; and
   3. E) Turning the electronic monitoring device off for the duration of a visit with a spiritual advisor, ombudsman, attorney, financial planner, intimate partner, or other visitor.
5. 8) Any other condition or restriction elected by the resident or roommate on the use of an electronic monitoring device. (Section 20(b) of the Act)