2015 version

Note: This TUE Application Form shall only be used if the Athlete, for any reason, cannot apply for a TUE from his/her own NADO/RADO (National/Regional Anti-Doping Organization). A TUE, approved by a NADO/RADO, will automatically be approved by IFSS, when a copy is submitted to the address below.

Reason not to use the NADO/RADO for application:

Please complete all sections in capital letters or typing. Athlete to complete sections 1, 5, 6 and 7; physician to complete sections 2, 3 and 4. Illegible or incomplete applications will be returned and will need to be re-submitted in legible and complete form.

Only substances that are on the current WADA Prohibited List need to have a TUE.

The complete form must be submitted to the chairperson of the IFSS Anti-Doping Committee via email at . The athlete shall keep a copy of the signed application for his/her own records. Questions may be asked at .

1. Athlete Information

Family Name(s): First Name(s)

2. Medical Information (continue on separate sheet if necessary)

Diagnosis with sufficient medical information:

If a permitted medication can be used to treat the medical condition, provide clinical justification for the requested use of the prohibited substance.

Note / Diagnosis
Evidence confirming the diagnosis shall be attached and forwarded with this application. The medical evidence should 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, and in the case of non-demonstrable conditions, independent supporting medical opinion will assist this application.

3. Medical details

Prohibited substance(s):
Generic Name / Dose / Route of Administration / Frequency / Duration of Treatment
1.
2.
3.
4.

4. Medical Practitioner’s Declaration

5. Retroactive applications

Is this a retroactive application?

Yes _____ No ______

If yes, on what date was the treatment started? ______

Please indicate reason:

Emergency treatment or treatment of an acute medical condition was necessary Yes _____ No ______

Due to other exceptional circumstances, there was insufficient time or opportunity to submit an application prior to sample collection Yes _____ No ______

Advance application not required under applicable rules Yes _____ No ______

Other:

Please explain: ______

6. Previous applications

7. Athlete’s Declaration

Incomplete Applications will be returned and will need to be resubmitted.

Please submit the completed form to the ADO () and keep a copy for your records.

TUE Form 2015 STRICTLY CONFIDENTIAL Page 1 of 3