57035d7950aaf-BCCI TUE Application Form V1.2015 PDF

Application No.
Therapeutic Use Exemptions (TUE) Application Form

The Board of Control for Cricket in India (BCCI)
Please complete ALL sections in CAPITAL LETTERS or typing. Incomplete applications will be returned. To
complete this document electronically, please type where indicated, and do NOT insert additional lines. This
document must be submitted in 3 pages.
I hereby apply for approval from the Board of Control for Cricket in India (BCCI) for the therapeutic use of a
substance and/or method on the WADA Prohibited List.
SECTION 1 and 6 should be completed by the athlete
1. PLAYER INFORMATION
Family Name(s): First Name(s):
Female Male (select appropriate box) Date of birth (dd/mm/yy):
Address:
State and Country: City & Post Code
If player with disability, indicate disability:
Sport: Discipline/Position
International or national Sports Organization
I am part of an International Federation Registered I am part of a National Anti-Doping Organization Testing

Testing Pool Pool
I am participating in an International Federation event for which a TUE granted pursuant to the International Federation’s
rules is required. Name of the competition
None of the above
Please include Country Code and Area Code, and select one option where the reply to be sent to
Contact Tel: Mobile/Cell:
E-mail address : Fax number:
Application history
Have you previously submitted a TUE Application: Yes No
For which substance(s) (generic name) To which organisation?

When was it submitted? Decision: Approved Not Approved
SECTION 3 to 5 should be completed by the medical practitioner
2. NOTIFYING MEDICAL PRACTITIONER

Family Name(s): First Name(s):
Qualifications(MD): Medical Speciality e.g. gastroenterologist
Address:
State and Country: City &Postcode:
Please include Country Code and Area Code, and select one option where the reply to be sent to
Contact Tel: Mobile/Cell
E-mail: Fax number:
BCCI TUE application form v1. 2015 Strictly confidential

Page 1 of 3
Application No.
3. MEDICATION INFORMATION: DIAGNOSIS WITH SUFFICIENT MEDICAL INFORMATION

Evidence confirming the diagnosis must be provided in support of this application. In those cases where this evidence is not
written in English, a summary in English should be enclosed. The medical evidence should include a comprehensive medical
history and summarise the results of all relevant examinations, laboratory investigations and imaging studies. Copies of the
original reports or letters should be included where possible. Evidence should be as objective as possible in the clinical
circumstances and, in the case of non-demonstrable conditions, independent supporting medical opinion should be provided.
Patient’s Name:
Female Male (select appropriate box) Date of birth (dd/mm/yy):
Diagnosis:
Medical Examination(s)/Test(s) Performed: Please indicate the name of the tests and attach a copy of
the examination reports when you submit TUE form if the athlete has any.
Physical examination Yes, specify and attach a copy.

N/A
Laboratory investigation Yes, specify and attach a copy.

N/A
Imaging studies Yes, specify and attach a copy.
N/A
Psychiatric/psychological report Yes, specify and attach a copy.

N/A
Others relevant medical examination Yes, specify and attach a copy.
N/A
N.B. All TUEs are subject to review at any time by the BCCI TUEC and/or WADA TUEC.
4. MEDICATION DETAILS
Prohibited Treatment Treatment
Dosage, Strength & Frequency Route of
Substance(s)/Methods(s) starts finishes
(including number of e.g. pills/puffs) administration
Generic Name (dd/mm/yy) (dd/mm/yy)
Example:
Dexamethasone 1× 8 mg once only Intravenous 01/01/10 01/03/10
Complete this section ONLY in the case of emergency treatment/exceptional circumstances*

* In case of emergency treatment or treatment of an acute medical condition, or exceptional circumstances (for retroactive
approval), please indicate all relevant information to explain the emergency and/or why the TUE application could not be
submitted in advance of the treatment.
If a non-Prohibited Substance(s) can be used to treat the specified medical condition, provide clinical justification for the
requested prohibited substance(s)/medication(s) below:

Page 2 of 3
Application No.
5. MEDICAL PRACTITIONER’S DECLARATION

I, (First name) (Family name)
Certify that the above-mentioned treatment is medically appropriate and that the use of alternative substances/medications not
on the WADA Prohibited List would be unsatisfactory for this condition:
Please indicate the medical condition below:
Medical Practitioner’s Date

Signature: (dd/mm/yy):
5. PLAYER’S DECLARATION
I, (First name) (Family name)
Certify that the information in Section 1 is accurate and that I am requesting approval to use the following Substance(s) or
Method(s) from the WADA Prohibited List:
Please indicate the name of the substances (Generic Name):
I authorize the release of personal medical information to the Board of Control for Cricket in India (BCCI) 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 provisions of the Code.
I understand that my information will only be used for evaluating my TUE request and in the context of possible anti-doping
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 these organizations to obtain my health
information, I must notify my medical practitioner and BCCI 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 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.
Date
Player’s Signature (dd/mm/yy):
If the player is a minor or has a disability preventing him/her from signing this form, a parent or guardian shall sign together
with, or on behalf of, the player.
Date
Parent’s/Guardian’s (dd/mm/yy):
Signature:
Please submit the COMPLETED form (keeping a copy for your records) to:
International Doping Tests & Management,
Email: [email protected] Fax: +46 8 555 10 995

Page 3 of 3

57035d7950aaf-BCCI TUE Application Form V1.2015 PDF

Uploaded by

Copyright:

Available Formats

57035d7950aaf-BCCI TUE Application Form V1.2015 PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

57035d7950aaf-BCCI TUE Application Form V1.2015 PDF

Uploaded by

Copyright:

Available Formats

Application No.

Therapeutic Use Exemptions (TUE) Application Form

Female Male (select appropriate box) Date of birth (dd/mm/yy):

State and Country: City & Post Code

If player with disability, indicate disability:

International or national Sports Organization

I am part of an International Federation Registered I am part of a National Anti-Doping Organization Testing

None of the above

E-mail address : Fax number:

Have you previously submitted a TUE Application: Yes No

For which substance(s) (generic name) To which organisation?

SECTION 3 to 5 should be completed by the medical practitioner

2. NOTIFYING MEDICAL PRACTITIONER

Qualifications(MD): Medical Speciality e.g. gastroenterologist

State and Country: City &Postcode:

E-mail: Fax number:

BCCI TUE application form v1. 2015 Strictly confidential

3. MEDICATION INFORMATION: DIAGNOSIS WITH SUFFICIENT MEDICAL INFORMATION

Female Male (select appropriate box) Date of birth (dd/mm/yy):

Physical examination Yes, specify and attach a copy.

Laboratory investigation Yes, specify and attach a copy.

Psychiatric/psychological report Yes, specify and attach a copy.

Complete this section ONLY in the case of emergency treatment/exceptional circumstances*

BCCI TUE application form v1. 2015 Strictly confidential

5. MEDICAL PRACTITIONER’S DECLARATION

Medical Practitioner’s Date

BCCI TUE application form v1. 2015 Strictly confidential

You might also like