Annexe 2

THERAPEUTIC USE EXEMPTION (TUE) APPLICATION FORM

PLEASE COMPLETE ALL SECTIONS IN CAPITAL LETTERS OR TYPING. PLAYER TO COMPLETE SECTIONS 1, 2, 3
AND 7; PHYSICIAN TO COMPLETE SECTIONS 4, 5 AND 6. ILLEGIBLE OR INCOMPLETE APPLICATIONS WILL BE
RETURNED AND WILL NEED TO BE RE-SUBMITTED IN LEGIBLE AND COMPLETE FORM.

NOTE THAT THIS TUE APPLICATION FORM AS WELL AS THE ENTIRE MEDICAL FILE (INCLUDING ALL REPORTS
AND DOCUMENTS) MUST BE COMPLETED IN ONE OF THE THREE OFFICIAL FIFA LANGUAGES (ENGLISH,
FRENCH OR SPANISH).

1. PLAYER INFORMATION
SURNAME: FIRST NAME(S):

FEMALE ☐ MALE ☐ DATE OF BIRTH (DAY/MONTH/YEAR)

ADDRESS:

CITY: COUNTRY:

TEL.: EMAIL:

NATIONALITY

NAME OF CLUB OR NATIONAL FOOTBALL ASSOCIATION:

IF YOU ARE A PLAYER WITH AN IMPAIRMENT, PLEASE INDICATE THE IMPAIRMENT

PLEASE MARK THE APPROPRIATE BOX:

☐ I AM PART OF THE FIFA PRE-COMPETITION TESTING POOL (PCTP)

☐ I AM PARTICIPATING IN A FIFA COMPETITION5: (NAME OF FIFA COMPETITION)

☐ I AM PART OF A NATIONAL ANTI-DOPING ORGANISATION (NADO) TESTING POOL: (NAME OF NADO)

☐ NONE OF THE ABOVE

REPLY TO BE SENT:
☐ By email: ADDRESS

☐ By post: ADDRESS

2. PREVIOUS APPLICATIONS

HAVE YOU SUBMITTED ANY PREVIOUS TUE APPLICATION(S) TO AN ADO FOR THE SAME CONDITION?

5
Please refer to the FIFA TUE policy, which is published on [Link]/who-we-are/legal/anti-doping/tue/, for the list of the
designated competitions.

FIFA TUE Policy – 2024 13

To whom? When?

Decision: Approved ☐ Not approved ☐

3. RETROACTIVE APPLICATIONS

IS THIS A RETROACTIVE APPLICATION?

Yes ☐ No☐
If yes, on what date was treatment started?

DO ANY OF THE FOLLOWING EXCEPTIONS APPLY? (ARTICLE 4.1 OF THE ISTUE):

☐ You required emergency or urgent treatment of a medical condition.

☐ There was insufficient time, opportunity or other exceptional circumstances that prevented you from
submitting the TUE application, or from having it evaluated, before getting tested.

☐ You were not permitted or required to apply in advance for a TUE as per
anti-doping rules.
☐ You tested positive after using a substance out-of-competition that was only prohibited in-competition
e.g. S9 glucocorticoids

Please explain (if necessary, attach further documents):

☐ Other retroactive applications (ISTUE, article 4.3)

In rare and exceptional circumstances notwithstanding any other provision in the ISTUE, a player may apply for
and be granted retroactive approval for their TUE if, considering the purpose of the Code, it would be
manifestly unfair not to grant a retroactive TUE.

In order to apply under article 4.3, please include a full reasoning and attach all necessary supporting
documentation.

Please explain (if necessary, attach further documents):

FIFA TUE Policy – 2024 14

4. MEDICAL INFORMATION (PLEASE ATTACH RELEVANT MEDICAL DOCUMENTATION)

DIAGNOSIS WITH DETAILED MEDICAL INFORMATION (SEE NOTE 1 BELOW):

NOTE 1 – DIAGNOSIS

Evidence confirming the diagnosis must be attached to 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 whenever possible. In addition, a short summary that
includes the diagnosis, key elements of the clinical exams, medical tests and the treatment plan would be helpful.

If a permitted medication can be used to treat the medical condition, please provide justification for the TUE for the
prohibited medication.

WADA maintains a series of guidelines to assist players and physicians in the preparation of complete and thorough
TUE applications. These TUE Guidelines can be accessed by entering the search term “Checklist” on the WADA
website: [Link]

5. MEDICATION DETAILS (CONTINUE ON SEPARATE SHEET IF NECESSARY)

PROHIBITED SUBSTANCE(S) – DOSE ROUTE OF FREQUENCY OF DURATION OF

1.
2.
3.

FIFA TUE Policy – 2024 15

I certify that the information in sections 4 and 5 above is accurate. I acknowledge and agree that my personal
information may be used by FIFA to contact me regarding this TUE application, to verify the professional
assessment in connection with the TUE process, or in connection with anti-doping rule violation investigations
or proceedings. I further acknowledge and agree that my personal information will be uploaded to the Anti-
Doping Administration and Management System (ADAMS) for these purposes (see FIFA’s Data Protection Portal
and the ADAMS Privacy Policy for more details).

I certify that the information in sections 2 and 3 above is accurate, and that the above-mentioned treatment is
medically appropriate.

NAME:

MEDICAL SPECIALITY:

LICENCE NUMBER: LICENCE BODY:

ADDRESS: (ADDRESS)

TEL.: EMAIL:

MOBILE: FAX:

SIGNATURE OF MEDICAL PRACTITIONER: DATE:

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I, , certify that the information set out at sections 1, 2, 3 and 7 is accurate

I authorise my physician(s) to release the medical information and records that they deem necessary to
evaluate the merits of my TUE application to the following recipients: the Anti-Doping Organization(s) (ADO)
responsible for making a decision to grant, reject or recognise my TUE; the World Anti-Doping Agency (WADA),
who is responsible for ensuring that determinations made by ADOs respect the ISTUE; the physicians who are
members of relevant ADO(s) and WADA TUE Committees (TUECs) who may need to review my application in
accordance with the World Anti-Doping Code and International Standards; and, if needed to assess my
application, other independent medical, scientific or legal experts.

I further authorise FIFA to release my complete TUE application, including supporting medical information and
records, to other ADO(s) and WADA for the reasons described above, and I understand that these recipients
may also need to provide my complete application to their TUEC members and relevant experts to assess my
application.

I have read and understood the TUE Privacy Notice (below), explaining how my personal information will be
processed in connection with my TUE application, and I accept its terms.

PLAYER’S SIGNATURE: DATE:

PARENT/GUARDIAN’S SIGNATURE: DATE:

(If the player is a minor or has an impairment preventing the player from signing this form, a parent or guardian shall sign with or on behalf of
the player.)

INCOMPLETE OR ILLEGIBLE APPLICATIONS WILL BE RETURNED AND WILL NEED TO BE RESUBMITTED.

PLEASE SUBMIT THE COMPLETED FORM TO THE CONFIDENTIAL EMAIL ADDRESS OF THE FIFA ANTI-
DOPING UNIT. AS A FIRST STEP, PLEASE SEND A FORMAL EMAIL ONLY TO ANTIDOPING@[Link],
WITHOUT ATTACHING THE TUE APPLICATION FORM OR RELEVANT MEDICAL DOCUMENTS. FIFA WILL
SEND YOU A PERSONALISED LINK TO AN ENCRYPTED FOLDER. YOU WILL THEN BE ASKED TO UPLOAD
THE TUE APPLICATION FORM AND THE RELEVANT MEDICAL DOCUMENTS INTO THAT ENCRYPTED
FOLDER. PLEASE NEVER SEND PERSONAL INFORMATION OVER EMAIL.

FIFA TUE Policy – 2024 17

This notice describes the personal information processing that will occur in connection with your submission
of a TUE application.

TYPES OF PERSONAL INFORMATION (PI)

The information provided by you or your physician(s) on the TUE Application Form (including your name, date
of birth, contact details, sport and discipline, the diagnosis, medication and treatment relevant to your
application);

Supporting medical information and records provided by you or your physician(s); and

Assessments and decisions on your TUE application by ADOs (including WADA) and their TUE Committees and
other TUE experts, including communications with you and your physician(s), relevant ADOs or support
personnel regarding your application.

PURPOSES AND USE

Your PI will be used in order to process and evaluate the merits of your TUE application in accordance with the
International Standard for Therapeutic Use Exemptions. In some instances, it could be used for other purposes
in accordance with the World Anti-Doping Code (“Code”), the International Standards, and the anti-doping rules
of ADOs with authority to test you. This includes:

Results management, in the event of an adverse or atypical finding based on your sample(s) or the Athlete
Biological Passport; and

In rare cases, investigations or related procedures in the context of a suspected Anti-Doping Rule Violation
(ADRV).

TYPES OF RECIPIENTS

Your PI, including your medical or health information and records, may be shared with the following:

 ADO(s) responsible for making a decision to grant, reject or recognise your TUE, as well as their delegated
third parties (if any). The decision to grant or deny your TUE application will also be made available to ADOs
with testing authority and/or results management authority over you;

 WADA authorised staff;

 Members of the TUE Committees (TUECs) of each relevant ADO and WADA; and

 Other independent medical, scientific or legal experts, if needed.

Note that due to the sensitivity of TUE information, only a limited number of ADO and WADA staff will receive
access to your application. ADOs (including WADA) must handle your PI in accordance with the International
Standard for the Protection of Privacy and Personal Information (ISPPPI). You may also consult the ADO to
which you submit your TUE application to obtain more details about the processing of your PI.

Your PI will also be uploaded to ADAMS by the ADO that receives your application so that it may be accessed
by other ADOs and WADA as necessary for the purposes described above. ADAMS is hosted in Canada and is
operated and managed by WADA. For details about ADAMS, and how WADA will process your PI, consult the
ADAMS Privacy Policy (ADAMS Privacy Policy).

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When you sign the Player Declaration, you are confirming that you have read and understood this TUE Privacy
Notice. Where appropriate and permitted by applicable law, ADOs and other parties mentioned above may
also consider that this signature confirms your express consent to the PI processing described in this notice.
Alternatively, ADOs and these other parties may rely upon other grounds recognised in law to process your PI
for the purposes described in this notice, such as the important public interests served by anti-doping, the
need to fulfil contractual obligations owed to you, the need to ensure compliance with a legal obligation or a
compulsory legal process, or the need to fulfil legitimate interests associated with their activities.

RIGHTS

You have rights with respect to your PI under the ISPPPI, including the right to a copy of your PI and to have
your PI corrected, blocked or deleted in certain circumstances. You may have additional rights under applicable
laws, such as the right to lodge a complaint with a data privacy regulator in your country.

Where the processing of your PI is based on your consent, you can revoke your consent at any time, including
the authorisation to your physician to release medical information as described in the Player Declaration. To
do so, you must notify your ADO and your physician(s) of your decision. If you withdraw your consent or object
to the PI processing described in this notice, your TUE will likely be rejected as ADOs will be unable to properly
assess it in accordance with the Code and International Standards.

In rare cases, it may also be necessary for ADOs to continue to process your PI to fulfil obligations under the
Code and the International Standards, despite your objection to such processing or withdrawal of consent
(where applicable). This includes processing for investigations or proceedings related to ADRV, as well as
processing to establish, exercise or defend against legal claims involving you, WADA and/or an ADO.

SAFEGUARDS

All information contained in a TUE application, including the supporting medical information and records, and
any other information related to the evaluation of a TUE request, must be handled in accordance with the
principles of strict medical confidentiality. Physicians who are members of a TUE Committee and any other
experts consulted must be subject to confidentiality agreements.

Under the ISPPPI, ADO staff must also sign confidentiality agreements, and ADOs must implement strong
privacy and security measures to protect your PI. The ISPPPI requires ADOs to apply higher levels of security
to TUE information because of the sensitivity of this information. You can find information about security in
ADAMS by consulting the response to “How is your information protected in ADAMS?” in the ADAMS Privacy
and Security FAQs.

RETENTION

Your PI will be retained by ADOs (including WADA) for the retention periods described in Annex A of the ISPPPI.
TUE certificates or rejection decisions will be retained for ten years. TUE application forms and supplementary
medical information will be retained for 12 months from the expiry of the TUE. Incomplete TUE applications
will be retained for 12 months.

CONTACT

Consult FIFA at antidoping@[Link] for questions or concerns about the processing of your PI. To contact
WADA, use privacy@[Link].

FIFA TUE Policy – 2024 19