Therapeutic Use Exemptions Form

Therapeutic Use Exemptions (TUE) Application Form

Please complete all sections in capital letters or typing. Athlete to complete sections 1 and 6; physician to complete sections 2, 3, 4 and 5. Illegible or incomplete applications will be returned and will need to be re-submitted in legible and complete form.

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Athlete Information

First name *
Last Name *
Date of Birth *
Sex *
Preferred method of communication: *
Phone *
Email *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Sport:
Text *
Are you in your international federation’s registered testing pool? *
If you know you will be competing at an international event, enter the event name and date: If you are *
If you are an athlete with a disability, indicate disability:

Previous TUE

Have you submitted any previous TUE application? *
YesNo
For which substances?
To which organization?
When?
Decision

Medical Information

Diagnosis -please attach sufficient medical information
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If a permitted medication can be used to treat the medical condition, provide clinical justification for the requested use of the prohibited medication:
Comment: Evidence confirming the diagnosis shall be attached and forwarded with this application. The medical information must include a comprehensive medical history and the results of all relevant examinations, laboratory investigations and imaging studies. Copies of the original reports or letters should be included when possible. Evidence should be as objective as possible in the clinical circumstances. In the case of non-demonstrable conditions, independent supporting medical opinion will assist this application. WADA maintains a series of guidelines to assist physicians in the preparations of complete and thorough TUE applications. These TUE Physician guidelines can be accessed by entering the search term “Medical Information” on the WADA website: https;//www.wada-ama.org The guidelines address the diagnosis and treatment of a number of medical conditions commonly affecting athletes, and requiring treatment with prohibited substances.
Medical Details (to be completed by your physician)

Prohibited Substance(s):

Generic name
Dose
Route of Administration
Frequency of Administration
Duration of Treatment

Generic name
Dose
Route of Administration
Frequency of Administration
Duration of Treatment

Generic name
Dose
Route of Administration
Frequency of Administration
Duration of Treatment

Physician’s Declaration (to be completed by your physician)

I certify that the above-mentioned treatment is medically appropriate and that the use of alternative medication not on the WADA Prohibited List would be unsatisfactory for this condition.
First Name
Last name:
Medical Specialty:
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
Email

nosing physician (if different from treating physician)

First Name: *
Last Name
Medical Specialty:
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email
Phone

Athlete’s Declaration

I, certify that the information set out at section 1, is accurate. I authorize the release of personal medical information to the Anti-Doping Organization (ADO) as well as to WADA authorized staff, to the WADA TUEC (Therapeutic Use Exemption Committee) and to other ADO TUECs and authorized staff that may have a right to this information under the World Anti-Doping Code (“Code”) and/or the International Standards for Therapeutic Use Exemptions. I consent to my physician(s) releasing to the above persons any health information that they deem necessary in order to consider and determine my application. I understand that my information will only be used for evaluating my TUE request and in the context of potential antidoping rule violation investigations and procedures. I understand that if I ever wish to (1) obtain more information about the use of my health information; (2) exercise my right of access and correction: or (3) revoke the right of these organizations to obtain my health information, I must notify my medical practitioner and my ADO in writing of that Therapeutic Use Exemptions (TUE) Application Form fact. I understand and agree that it may be retained for the sole purpose of establishing a possible anti-doping rule violation, where this is required by the Code. I consent to the decision on this application being made available to all ADOs, or other organizations, with Testing authority and /or results management authority over me. I understand and accept that the recipients of my information and of the decision on this application may be located outside of the country where I reside. In some of these countries data protection and privacy laws may not be equivalent to those in my country of residence. I understand that if I believe that my Personal Information is not used in conformity with this consent and the International Standard for the Protection of Privacy and Personal Information, I can file a complaint to WADA or CAS.
I authorize the release of my medical information to members of the Health Care Team attending Major Games where I may participate, to my Team Physician, and to my national sport organization.
Checkbox
Option 1Option 2Option 3
I do not wish to have this information shared with anyone but the, WADA and my international federation.

Verification

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