Medical declaration form for an ioc restricted substance

ABBREVIATED THERAPEUTIC USE EXEMPTION FORM

Please complete all sections in capital letters or typing. Illegible forms will be
returned.
beta-2 agonists by inhalation ‰
glucocorticosteroids by ‰
non-systemic routes *

* All routes other than orally, rectally, intravenously and intramuscularly.
Topical glucocorticosteroid preparations to treat aural/otic, nasal, buccal cavity and ophthalmic
ailments are not prohibited and do not require a Therapeutic Use Exemption
Note: Despite the granting of a TUE, when the Laboratory has reported a concentration of salbutamol
(free plus glucuronide) greater than 1000 ng/mL this will be considered as an Adverse Analytical
Finding unless the athlete proves that the abnormal result was the consequence of the therapeutic use
of inhaled salbutamol.
NB - TUE FORMS AND ALL REPORTS AND ACCOMPANYING
DOCUMENTS MUST BE COMPLETED IN ENGLISH.
1. Athlete Information
Female ‰ Male ‰ Date of Birth (d/m/y): ……………………………………. Tel.: …………………………………………………………… E-mail : ……………………………………………………………. (with international code) International or National Sporting Organization: . 2. Medical information
Diagnosis: …………………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. N.B. Any ATUE may be reviewed at any time, by the ADO and/or WADA
STRICTLY CONFIDENTIAL
Version 2.0/18 July 2007
Prohibited substance(s):
Frequency Date(s)
Generic name
Treatment

Intended duration of
treatment:
(Please tick appropriate box) or duration (week/month): ………………………………
3. Medical practitioner’s and athlete’s declaration
I certify that the above-mentioned treatment is medically appropriate and that the use of
alternative medications not on the Prohibited List would be unsatisfactory for this condition.
Name: …………………………………………………………………………………………………………
Medical Speciality: ……………………………………………………………………………………….
Address: ……………………………………………………………………………………………………….
Tel.: …………………………. Fax: ……………………………………………….
E-mail: ………………………………………………………………………………………………………….
Signature of Medical Practitioner: . Date: .

I, ……………………………………………………………… certify that the information under 1. is accurate
and that I am requesting approval to use a Substance or Method from the WADA Prohibited List. I authorize the release of personal medical information to the Anti-Doping Organization (ADO) as well as to WADA staff, to the WADA TUEC (Therapeutic Use Exemption Committee) and to other ADO under the provisions of the Code. I understand that if I ever wish to revoke the right of these organizations to obtain my health information on my behalf, I must notify my medical practitioner and my ADO in writing of that fact.
Athlete’s signature: . Date: .

Parent’s/Guardian’s signature: . Date: .
(if the athlete is a minor or has a disability preventing him/her to sign this form, a parent or guardian
shall sign together with or on behalf of the athlete)
Incomplete Applications will be returned and need to be resubmitted.
Please submit the completed form to the South African Institute for Drug-Free
Sport for the attention of Pamela Isaacs: Fax - 021 683 7274/ email:
[email protected]

Source: http://bpsu.co.za/TUE_Non_Systemic.pdf