National Anti Doping Agency

(An Autonomous Body Under Ministry of Youth Affairs & Sports, Government of India)
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THERAPEUTIC USE EXEMPTIONS

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.

1. Athlete Information

Surname: ___________________________ Given Names: ________________________________

Female Male Date of Birth (DD/MM/YY) ______________________

Address: ________________________________________________________________________

City: _________________________ Country: ____________________ Postcode: ____________

Tel.: _____________________________ E-mail: _______________________________________

(with international code)

Sport: _____________________________ Discipline/Position: ___________________________

International or National Sport Organization of the sport cod that you are competing in:

______________________________________________________________________________

Next Competition date : ________________________________________________

If you are an Athlete with impairment, please indicate the impairment;

_____________________________________________________________________________

_____________________________________________________________________________

F01 (NADA-P-04) Page 1 of 5

‘A’ Block, Pragati Vihar Hostel, Lodhi Road, New Delhi-110003, India.
Phone: +91-11-24368274, +91-11-24368249, Telefax: +91-11-24368248, E.Mail: [email protected],
Website: www.nada.nic.in
 National Anti Doping Agency
(An Autonomous Body Under Ministry of Youth Affairs & Sports, Government of India)
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2. Medical information: (continue on separate sheet if necessary)

Diagnosis
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

If a permitted medication can be used to treat the medical condition, please provide clinical
Comment:
justification for the requested use of the prohibited medication
________________________________________________________________________________
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.
________________________________________________________________________________
__________________________________________________________________
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 preparation 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.

F01 (NADA-P-04) Page 2 of 5

‘A’ Block, Pragati Vihar Hostel, Lodhi Road, New Delhi-110003, India.
Phone: +91-11-24368274, +91-11-24368249, Telefax: +91-11-24368248, E.Mail: [email protected],
Website: www.nada.nic.in
 National Anti Doping Agency
(An Autonomous Body Under Ministry of Youth Affairs & Sports, Government of India)
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3. Medication details

Prohibited Trade Dosage Route of Frequency Date(s) of Duration of

substance(s): Name administration treatment Treatment
Generic
name/active
ingredient
1.

2.

3.

4.

5.

4. Medical practitioner’s declaration

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

Name: ________________________________________________________________________

Medical specialty: ______________________________________________________________

Address: ______________________________________________________________________
Tel.: __________________________________________________________________________
Fax: _______________________________________ __________________________________
E-mail:_______________________________________________________________________
5. Athlete’s
Signature ofdeclaration
Medical Practitioner: ____________________________________ Date: _________

5. Athlete’s declaration

F01 (NADA-P-04) Page 3 of 5

‘A’ Block, Pragati Vihar Hostel, Lodhi Road, New Delhi-110003, India.
Phone: +91-11-24368274, +91-11-24368249, Telefax: +91-11-24368248, E.Mail: [email protected],
Website: www.nada.nic.in
 National Anti Doping Agency
(An Autonomous Body Under Ministry of Youth Affairs & Sports, Government of India)
Play fair
5. Retroactive Applications

Is this a retroactive Please indicate reason:

application?
Emergency treatment or treatment of an acute medical
condition was necessary
Yes:
Due to other exceptional circumstances, there was
insufficient time or opportunity to submit an application
No: prior to sample collection

If yes, on what date was Advance application not required under applicable rules
treatment started ?

Other

Please explain:________________________________
______________________________________________
______________________________________________

6. Previous applications

Have you submitted any previous TUE application(s)?

No Yes

Kindly indicate the TUE approval number (if applicable)___________________________

For which substance or method?

To Whom_____________________When ?____________________________________

Decision: Approved Not approved

F01 (NADA-P-04) Page 4 of 5

‘A’ Block, Pragati Vihar Hostel, Lodhi Road, New Delhi-110003, India.
Phone: +91-11-24368274, +91-11-24368249, Telefax: +91-11-24368248, E.Mail: [email protected],
Website: www.nada.nic.in
 National Anti Doping Agency
(An Autonomous Body Under Ministry of Youth Affairs & Sports, Government of India)
Play fair
7. Athlete’s declaration

I, _________________________________________, certify that the information set out at

sections 1, 5 and 6 is accurate. I authorize the release of personal medical information to the
National Anti-Doping Agency, India (NADA, India) 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 Standard 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 anti-doping 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 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 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 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.

Athlete’s signature______________ Parent’s/Guardian’s signature ______________

Date ________________________ Date ________________________

(If the Athlete is a Minor or has an impairment preventing him/her signing this form, a parent
or guardian shall sign on behalf of the Athlete).

Please submit the completed form to NADA India by the following means (keeping a copy
for your records:-

By Post: National Anti Doping Agency, ‘A’ Block, Pragati Vihar Hostel, Lodhi Road, New
Delhi-110003, India Telefax: 011-24368248

By Email: [email protected]

F01 (NADA-P-04) Page 5 of 5

‘A’ Block, Pragati Vihar Hostel, Lodhi Road, New Delhi-110003, India.
Phone: +91-11-24368274, +91-11-24368249, Telefax: +91-11-24368248, E.Mail: [email protected],
Website: www.nada.nic.in