Therapeutic Use Exemptions TUEs Application Form Return to the IOC Medical Scientific Department By fax 41 21 621 6361 or by email tue-aut@olympic org Or at the Olympic village Polyclinic Please complete all sections in capital letters or typing 1 Athlete Information Surname First Names Female Date of Birth d m y Male Address City Country Postcode Tel with international code E-mail Sport Discipline Position International or National Sport Organization 2 Medical information Diagnosis with sufficient medical information see note 1 ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… If a permitted medication can be used to treat the medical condition provide clinical justification for the requested use of the prohibited medication ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… STRICTLY CONFIDENTIAL 3 Note Note 1 Diagnosis Evidence confirming the diagnosis must 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 The application must include a comprehensive medical history and the results of all examinations laboratory investigations and imaging studies relevant to the application The requirements for the medical file to be used for the TUE process in the case of asthma and its clinical variants must be fulfilled and include all pulmonary function tests Incomplete Applications will be returned and will need to be resubmitted Please submit the completed form to the IOC TUE Committee and keep a copy for your records 4 Medication details Prohibited substance s Generic name Dose Route Frequency 1 2 3 Intended duration of treatment Please tick appropriate box once only date… … … … …… emergency or duration week month Have you submitted any previous TUE application yes no For which substance To whom Decision Approved When Not approved STRICTLY CONFIDENTIAL 5 Medical practitioner’s declaration I certify that the above-mentioned treatment is medically appropriate and that the use of alternative medication not on the prohibited list would be unsatisfactory for this condition Name Medical speciality Address Tel Fax E-mail Signature of Medical Practitioner Date 6 Athlete’s declaration 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 IOC TUE Committee and to other relevant parties that may have a right to this information under the provisions of the World Anti-Doping Code I understand that my information will only be used for evaluating my TUE request and in the context of possible anti-doping rule violation investigations and procedures I understand that if I ever wish to 1 obtain more information about the use of my information 2 exercise my right of access and correction or 3 revoke the right of relevant organizations to obtain my health information on my behalf I must notify my medical practitioner and the IOC TUE Committee in writing of that fact I understand and agree that it may be necessary for TUE-related information submitted prior to revoking my consent to be retained for the sole purpose of establishing a possible anti-doping rule violation where it is required by the World Anti-Doping Code 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 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 FILE - SAVE AS FILE - PRINT STRICTLY CONFIDENTIAL