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Leichtathletik.de


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

First Name: . . . . . . . . . . . . . . . . . . . Last Name: . . . . . . . . . . . . . . . . . . . . . . . (tick appropriate box) Event: . . . . . . . . . . . . . . . . . . . . . . . . Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of birth (d/m/y): . . . . . . . . . . . . . . . . e-mail: . . . . . . . . . . . . . . . . . . . . . . . . . National Federation: . . . . . . . . . . . . . . . .
2. Notifying medical practitioner

Name, qualifications and medical speciality (see Note 1): . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City: . . . . . . . . . . . . . . . . State/Province: . . . . . . . . . . . Country . . . . . . . . . . . . . Post Code. . . . . . . . . . . . e-mail: . . . . . . . . . . . . . . . . . . . . . Tel. Work: . . . . . . . . . . . . . . . . . . . . . . . Tel. Home: . . . . . . . . . . . . . . . . . . Mobile: . . . . . . . . . . . . . . . . . . . . . . . . . Fax: . . . . . . . . . . . . . . . . . . . . . . .
3. Medical information

Diagnosis (see Note 2 for Beta-2 Agonists applications only): . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical examination(s)/test(s) performed: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Has the athlete’s National Federation Team Doctor been notified of this application?
Yes:

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

………………………………………………………………………………………….

……………………………………………………………………………….……………

……………………………………………………………………………….……………


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: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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>TUE Beta-2 Agonists>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 tue-applications@iaaf.org (e-mail).

Source: http://www.leichtathletik.de/dokumente/ergebnisse/uploads/antidoping/iaaf_tue_abbreviated.pdf

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