Athlete’s Name: ___________________________

The following sporting Federations require the use of a specific application form: Archery(FITA); Badminton(BWF); Basketball(FIBA); Bobsled and Skeleton (FIBT); Cycling(UCI); Field Hockey (FIH): Paralympic Athletes(IPC); Rowing(FISA); Tennis(ITF); Track and Field(IAAF); Wrestling(FILA); Volleyball(FIVB). If you compete in one of these sports, PLEASE make sure you have downloaded the correct form. If you submit the wrong form your application will be returned to you. For all other sports, please use the USADA TUE Application Form on the USADA website.

1. Download forms. Please be sure to download the appropriate TUE Application form for your sport AND the Specific Information for the medication or condition published by The World Anti-Doping Agency (WADA) and available from both the USADA and WADA website.

Procedure for Obtaining a Therapeutic Use Exemption for a Prohibited Substance.

There are additional pages attached to this form for applications for Beta-2 Agonists in the treatment of Asthma. Please ensure your physician fills out ALL of the relevant forms (Pages 2,3,7,8). If pages 7 and 8 are not filled out by your physician, your application will be returned to you. If you are not applying for a Beta-2 Agonist then disregard pages 5-8.

3. Submit the completed application by email, fax, or mail as detailed below. You should receive a confirmation of receipt within 3 business days. If you do not receive confirmation of receipt, please notify the TUE Administrator immediately. By Mail: United States Anti-Doping Agency ATTN: TUE Department 1330 Quail Lake Loop, Suite 260 Colorado Springs, CO 80906 By E-mail: tue@usada.org By Fax: (719) 785-2029

2. Bring all relevant documents to your physician. All forms must be filled out completely. Incomplete applications will NOT be submitted to the Therapeutic Use Exemption Committee for review, and cannot be approved. The documents detailing the medical information to support decisions of TUECs are very useful, and will help the physician provide information that will help in the decision process for this TUE application.

5. Await Decision. Your application will normally be processed within 21 days of receipt. Until you are formally granted a Therapeutic Use Exemption, the use of prohibited substances may result in a doping violation. We will formally notify you of a decision by email, and by postal mail. If your Therapeutic Use Exemption is granted, you will receive a formal Approval Letter and Certificate.
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4. Review of your Application. If your application is complete, it will be forwarded to the Therapeutic Use Exemption Committee of USADA or that of the relevant International Federation for your sport. It is very important that you notify us of your competition status, your membership in a Registered Testing Pool, and whether you intend to compete in an event sanctioned by your International Sporting Federation (whether the event takes place in the USA or abroad; You may need to consult the website of your International Federation to make this determination). Such information will determine who has the authority to grant your Therapeutic Use Exemption. Failure to provide this information, or the provision of incorrect information will result in delays in the processing of your Therapeutic Use Exemption.

TUE Administrator (719) 785-2045

Athlete’s Name: ___________________________

Therapeutic Use Exemption (TUE) Application Form
For International-Level Athletes, these Federations require their own application form which should be obtained from the USADA Website: Archery(FITA); Badminton(BWF); Basketball(FIBA); Cycling(UCI); Paralympic Athletes(IPC); Rowing(FISA); Tennis(ITF); Track and Field(IAAF); Wrestling(FILA); Volleyball(FIVB)

Sections 1, 4, and 6 – Completed By Athlete Sections 2, 3, 5 – Completed By Prescribing Physician For Beta-2 Agonists- Physicians Please read pages 5 and 6, and fill out pages 7 and 8. 1. Basic Athlete Information (Please print in BLOCK LETTERS.)
Last Name: ........................................................................... Female  Male  First Name:..........................................................................................

Date of Birth (month/day/year): ............................................................................................................

Mailing Address: ..................................................................................................................................................................................... City: ................................................................................... State: ............................................... Zip Code: ........................................ Work Phone: .......................................... Home Phone: ................................................ Mobile Phone: ....................................... Email: ..................................................................................................... Fax: ........................................................................................ International or National Sport :……………………………………………………………………………… Sporting Organization : ………………………………………………………………………….. CONFIRM YOUR COMPETITION STATUS 1 (please check all that apply) : USADAs Registered Testing Pool International Federation Testing Pool  Neither/unsure Please list the upcoming National/Internationally Sanctioned Events you intend to participate in: ……………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………

2. Medical information –For BETA-2 AGONISTS PLEASE ALSO fill in pages 6 and 7 (Physician
Worksheet). For all other medications you consult the relevant publication in note 2 (below). Diagnosis. Please attach additional sheets with sufficient medical information to support the diagnosis and necessity to use the prohibited substance (see below, note 2): use of the prohibited medication (attach additional sheets). ...................................................................................................................................................................................................................... ...................................................................................................................................................................................................................... …………………………………………………………………………………………………………………………………………………………………………………………………………………………..

............................................................................................

If a permitted medication can be used to treat the medical condition, provide clinical justification for the requested

Your competition status will determine who has the authority to grant this TUE. You may wish to contact the National Governing Body or the International Federation for your sport to confirm your competition status. 2 The physician and athlete should consult the relevant publication entitled Medical information to support the decisions of TUECs for the use of prohibited substance available on the World Anti-Doping Website www.wadaama.org/en/exemptions.ch2

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Athlete’s Name: ___________________________

3.

Medication details –(Please use BLOCK LETTERS)
Prohibited substance(s):

Generic name

Dose

Route

Frequency

1.

2.

3.

Intended duration of treatment: (Please tick appropriate box.)

 One-Time Only  Emergency (*If this is an emergency- please write EMERGENCY in block letters on the top of the application to expedite processing).  Long term (note duration: weeks/months): ……………………………………………..

4.

TUE Request History (Please type or print in block letters.)
yes  no 

Have you submitted any previous TUE application?:

For which substance? ………………………………………………………………………………………………………………… To whom (e.g. USADA, International Federation)?……………………………………………………………….When?……………/………………/…………… Decision: Approved  Not approved 

5. Medical practitioner’s declaration (Please type or print in block letters.)
I certify that the above-mentioned treatment is medically appropriate and that the use of alternative medications not on the Prohibited List would be unsatisfactory for this condition. Name: ......................................................................................................................................................................................................... Medical Speciality:................................................................................................................................................................................... Address: ..................................................................................................................................................................................................... Tel.: .................................................................................................... Fax (optional): ..........................................................................

E-mail (optional): ........................................................................................................................................................................................ Signature of Medical Practitioner: ............................................................................... Date: ......................................................

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Athlete’s Name: ___________________________

6. Athlete’s declaration
I, ....................................................................................... , certify that the information under section one is accurate and that I am requesting approval to use a Substance or Method from the World Anti-Doping Agency (WADA) Prohibited List. I authorize the release of personal medical information to USADA including its Therapeutic Use Exemption Committee (TUEC) as well as to WADA staff, to the WADA TUEC, and to the appropriate International Federations and their TUEC under the provisions of the WADA Code. I understand that if I ever wish to revoke the right of the Anti-Doping Organization TUEC or WADA TUEC to obtain my health information on my behalf, I must notify my medical practitioner in writing of that fact. I understand that International and National-Level Athletes should submit the Form to USADA and USADA will forward the Form to the appropriate Governing Body and/or TUEC. I understand that using any prohibited substance is at my own risk of committing a doping violation until my request has been approved and I receive approval in writing from USADA and/or my IF (if applicable).

Athlete’s signature: .......................................................................................... Date: Parent’s/Guardian’s signature: ..................................................................... Date:

............................................................................ ............................................................................

(If the athlete is a minor or has a disability preventing him/her to sign this form, a parent or guardian shall sign together with or on behalf of the athlete.)

7. Attention Diagnosis with sufficient medical information to support the diagnosis and necessity to use the prohibited substance should be included:
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. A statement by an appropriately qualified physician attesting to the necessity of the otherwise Prohibited Substance or Prohibited Method in the treatment of the athlete and describing why an alternative, permitted medication cannot, or could not, be used in the treatment of this condition should also be included.

Incomplete Applications will be returned and will need to be resubmitted.
No TUE will be in effect until the athlete is notified following review of the documentation after submission. Please submit the completed request to the U.S. Anti Doping Agency and keep a copy for your records. You should receive confirmation of receipt of this application within 3 business days.

If you do not receive confirmation, please contact the TUE Administrator immediately.
United States Anti-Doping Agency ATTN: TUE Department 1330 Quail Lake Loop, Suite 260 Colorado Springs, CO 80906 Fax: (719) 785-2029 Telephone (for TUE Questions): (866) 601-2632 (toll-free); TUE Administrator (719) 785-2045 Drug Reference Online: www.usada.org/dro Drug Reference Line: (800) 233-0393 or (719) 785-2020 (outside of the U.S.) or drugreference@usada.org E-mail: tue@usada.org Web Site: www.usada.org

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Athlete’s Name: ___________________________

Information for Athletes and Physicians regarding Therapeutic Use Exemptions for Beta-2 Agonists
Concerned about the increased use of Beta-2 agonists 3 by elite athletes, and the risks of using such medications long-term, the World Anti-Doping Agency has issued a new International Standard for Therapeutic Use Exemptions (2009) 4 that requires a medical file justifying the use of Beta-2 agonists. Information that would support your application includes:

History • Symptoms suggesting airway obstruction with exercise • Symptoms at rest and at night • Allergies or atopic disorders especially seasonal or environmental allergies • Identified triggering factors • Childhood asthma • Previous or current respiratory infection requiring beta-2 agonist treatment • Previous results of RAST or skin prick testing if pertinent • IgE • Total eosinophil count in peripheral blood • Sputum eosinophils Physical examination • Exam findings emphasizing the respiratory system (pathway) • Past pertinent exam findings (especially as related to initial diagnosis if available) Spirometry and/or Bronchial Provocation Test Results • Results of spirometry including forced expiratory volume in 1 second (FEV1) at rest AND in response to inhaled bronchodilator OR • Results of bronchial provocation tests (eucapnic voluntary hyperpnea, exercise challenge, hypertonic saline, mannitol inhalation or methacholine challenge) with response to inhaled bronchodilator Diagnosis • Definitive diagnosis • Differential diagnoses (hyperventilation syndrome, vocal cord adduction, exercise induced laryngomalacia, non-reversible airflow obstructive disease, heart failure). • Associated diagnoses Treatment • Details of strategies to manage known contributing factors to asthma/EIB such as rhinitis, nasal congestion and allergies • Attempts to manage symptoms with non-prohibited medications such as leukotriene receptor agonists, anticholinergics, sodium chromoglycate or theophyllines if appropriate

3 For discussion of rationale for change in policy regarding Beta-2 Agonists, see “Asthma and the elite athlete: Summary of the International Olympic Committee’s Consensus Conference, Lausanne Switzerland, January 22-24 2008” J Allergy Clin Immunol 2008;122:254-60. 4 The World Anti-Doping Agency International Standard for Therapeutic Use Exemptions 2009 (http://www.wadaama.org/rtecontent/document/TUE_Standard_2009_Final_031008.pdf)

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Athlete’s Name: ___________________________

In some instances, in order to produce test results that meet the criteria 5 for the diagnosis of asthma as adopted by the World Anti-Doping Agency, an athlete may have to cease taking their asthma medications for a short time preceding the test. Cessation of medication should ONLY be done under the careful supervision of the attending physician. The athlete may wish to discuss this possibility with their physician prior to the office visit to determine if this is an appropriate approach. WADA recommends athletes to stop taking short-acting Beta-2 agonists for 8 hours prior to testing, and to stop taking long-acting Beta-2 agonists and glucocorticosteroids 24 hours prior to testing. Further reference should be made to the American Thoracic Society. In cases where athletes have well controlled asthma and record negative responses to all of the tests, but still seeking approval for the use of inhaled Beta-2 agonists, substantial medical justification will be required to demonstrate the absolute necessity for Beta-2 agonists. Such information may include evidence of emergency room attendance or admission into hospital for acute exacerbation of asthma, treatment with oral corticosteroids, and a thorough medical file containing ALL of the information listed above. Please note: The US Anti-Doping Agency (in accordance with position statements by the IOC and WADA) recognizes the inherent risk of undertaking bronchial provocation tests, and the temporary cessation of medication that may be required to produce positive test results. For this reason, an advanced Therapeutic Use Exemption for Beta-2 agonists is only mandatory for athletes in the Registered Testing Pool of USADA or an International Sporting Federation, and for any athlete intending to compete at an event sanctioned by an International Sporting Federation regardless of whether they are in a registered testing pool 6. For athletes not in a registered testing pool, and not wishing to compete at an Internationally sanctioned event (non-national level athletes), you are only required to notify USADA in advance of your intention to use Beta-2 agonists through a Website Declaration on the USADA website (www.usada.org). However, according to WADA guidelines, any athlete may request an advance Therapeutic Use Exemption if they wish to do so. In the event of testing, you are also required to list the substance in the “Declaration of Use” section of the Doping Control Official Record at the time of collection.

For further information on WADA standard Therapeutic Use Exemption criteria please see the document entitled “Medical Information to Support the Decisions of TUECs- Asthma” published by the World Anti-Doping Agency on www.wada-ama.org 6 Please consult the document “USADA Policy for Therapeutic Use Exemptions and Declarations of Use” published www.usada.org.
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Athlete’s Name: ___________________________

**This form MUST accompany a TUE Application for a Beta-2 Agonist** PHYSICIAN- You must select one of the Objective Tests in the Table below and report the result. Please take note of the criteria set forth by WADA.
1. Spirometry and/or Bronchial Provocation Test Results (Select all that apply) 7. Has the patient had been on asthma medication in the days leading up to test(s)? YES NO (if no, how long has patient been off medications?______________) Check one Test Type
Spirometry: FEV1 Pre and Post Bronchodilator Methacholine aerosol challenge Mannitol Inhalation

WADA criteria
12% increase in FEV1 postbronchodilator 20% fall in FEV1; PC20<4mg/mL
(tidal breathing technique- steroid naive)

Please report test results with regard to fall in FEV1
Please note % change in FEV1:

Please note PD20 (µg) and/or PC20 (mg/mL) and % fall in FEV1:

15% fall in FEV1

FEV1 decrease of _____% in ______min. FEV1 decrease of _____% in ______min.

Eucapnic Voluntary Hyperpnea Hypertonic saline aerosol challenge Exercise challenge (field or laboratory)

10% fall in FEV1

15% fall in FEV1

FEV1 decrease of _____% in ______min. FEV1 decrease of _____% in ______min Method of challenge:__________________

10% fall in FEV1

Histamine Challenge

2. Please attach a complete and comprehensive history of asthma and symptom management (including the age of onset, severity of symptoms, identified triggering factors, hospital
emergency department attendance for acute exacerbation of symptoms, history of treatment with oral corticosteroids, past physical exams and spirometry test results, specific information on coughing, wheezing, chest tightness during or post exercise etc. Attach additional sheets)

3. Please attach physical exam report with a focus on the respiratory system.

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Test result criteria published www.wada-ama.org “Medical Information to Support the Decisions of TUECsAsthma”

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Athlete’s Name: ___________________________

4. Please comment on attempts to manage the asthma by non-prohibited medications (such
as leukotriene receptor antagonists, anticholinergics, sodium chromoglycate, or theophyllines. Please provide a clear statement why non-prohibited medications have not been effective or are otherwise inappropriate.)

5. Please note other considerations in the assessment of this patient’s asthma (i.e. other diagnoses, health concerns expressed by the athlete, parent etc.).

7. According to the Therapeutic Use Exemption International Standard, Section 4, published Jan 2009 by the World Anti Doping Agency, the criteria for granting a Therapeutic Use Exemption are as follows:
4.2 The Athlete would experience a significant impairment to health if the prohibited substance were withheld in the course of treating an acute or chronic medical condition 4.3 The therapeutic use of the prohibited substance would produce no additional enhancement of performance other than that which might be anticipated by a return to a state of normal health following the treatment of a legitimate medical condition. 4.4 There is no reasonable therapeutic alternative to the use of the otherwise prohibited substance. 4.5 The necessity for the use of the otherwise prohibited substance cannot be a consequence, wholly or in part, of prior non-therapeutic use of any substance from the prohibited list.

In your opinion, does the asthma history and present health status of this patient meet the above criteria? Please Comment.

Signature

Date:

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