Each facility shall use an electronic monitoring device acknowledgment form developed by the department and adopted by regulation. The form shall be offered to any resident or resident’s guardian or legal representative upon request. The form shall be completed and signed by or on behalf of a resident prior to the installation of, or any use of, an electronic monitoring device in the facility. The form shall state:

(1) That a person who places an electronic monitoring device in the room of a resident or who uses or discloses a tape or other recording made by the device may be civilly liable for any unlawful violation of the privacy rights of another;

(2) That a person who, without authorization, places an electronic monitoring device in the room of a resident or who consents to or acquiesces in the unauthorized placement of the device in the room of a resident has waived any privacy right the person may have had in connection with images or sounds that may be acquired by the device;

(3) That a resident or the resident’s guardian or legal representative is entitled to conduct authorized electronic monitoring, and that if the facility refuses to permit the electronic monitoring or fails to make reasonable physical accommodations for the authorized electronic monitoring, the person should contact the department;

(4) The basic procedures that shall be followed to request authorized electronic monitoring;

(5) The manner in which sections 198.610 to 198.632 affect the legal requirement to report abuse or neglect when electronic monitoring is being conducted; and

(6) Any other information regarding authorized or unauthorized electronic monitoring that the department, by regulation, specifies should be included on the form.