STRICTLY CONFIDENTIAL Application IAAF Therapeutic Use Exemptions Abbreviated Application Form [International]
[Beta-2 agonists by inhalation, Glucocorticosteroids by non-systemic routes]
I herby apply for approval for the therapeutic use of a prohibited substance on the IAAF Prohibited List that is subject to the Abbreviated TUE Application Procedure Please complete all sections
[PRINT information legibly using BLOCK capitals]
1. Athlete information
Name of National Federation’s Team Doctor (see Note 3): . . . . . . . . . . . . . . . . . . . . . . . . . 4. Medication details (see Note 4):
Anticipated duration of this
Medication plan (see Note 5): Additional information
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5. Medical practitioner’s declaration
I, . . . . . . . . . . . . . . . . . . . . . . . . . . certify that the above-mentioned medication(s) for the
above-named athlete has been/are to be administered as the correct treatment for the
above-named medical condition. I further certify that the use of alternative medications
not on the IAAF Prohibited List would be unsatisfactory for the treatment of the above-
named medical condition for the following reasons.
Specify reasons: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Signature of Medical Practitioner: . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . .
6. Athlete’s declaration
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . certify that the information in section 1 above is accurate and that I am requesting for approval to use a prohibited substance in the IAAF Prohibited List. I authorize, if necessary, the release of my personal medical information to the members of the IAAF Therapeutic Use Exemption Sub-Commission, as well as to any other relevant persons (including, where applicable, WADA or IOC staff and/or members of the WADA or IOC Therapeutic Use Exemption Committees) who may be involved in the management, review or administration of my application in accordance with the IAAF Procedural Guidelines. I understand that, if I ever wish to revoke the right of the IAAF TUESC to obtain any health information on my behalf, I must notify my medical practitioner in writing of the fact. As a consequence of such a decision, I understand that I will not receive approval for a TUE (or renewal of an existing TUE). I further authorise for the decision of the IAAF TUESC to be notified to any other relevant organisations in accordance with IAAF Rule 34.5. Athlete’s signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . Parent’s/Guardian’s signature: . . . . . . . . . . . . . . . . . . . . Date: (if the athlete is a minor, a parent or guardian shall sign together with or on behalf of the athlete) Note 1 Name, qualifications and medical specialty For example: Dr AB Cook, MD FRACP, Gastro-enterologist. Dr JA Gonzalez. MBBS, FACSM, Sports Physician
Note 2 Diagnosis and Medical examination(s)/test(s) performed For applications for the use of Beta-2-agonists only: To constitute a complete application, International-Level athletes/athletes preparing to compete in an International competition must include the following documentation required by the IAAF Beta-2-Agonists Protocol: 1. Detailed Medical Records. 2. Provocation Test Results. Refer to the IAAF Beta-2 Agonists Protocol (www.iaaf.org>Anti- Doping>Downloads>Beta-2 Agonists Protocol) for further more detailed information on the documentation that is required. Note 3 National Federation Team Doctor Where possible, the National Federation Team Doctor should be notified of the application.
Note 4 Medication details/change of Prescription
Provide both the commercial and generic name (INN) of the medication and specify medication dose, the route of administration and the frequency of administration. Note that a new TUE application will be required for any change of prescription.
WARNING: Incomplete Applications will be returned and will need to be re-submitted. Please submit the completed application to the IAAF Medical and Anti-Doping Department (see contact details below) and keep a copy of the Form for your records: IAAF Medical and Anti-Doping Department
17, Rue Princesse Florestine BP 359 – MC 98007 Monaco Confidential Fax: +377 93 50 83 95 If there are any questions arising from this Form or regarding the relevant procedures for abbreviated applications for TUEs on an international level, please contact the IAAF for further information on: +377 93 10 88 89/56 (tel) or [email protected] (e-mail).
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