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Therapeutic Use Exemption (TUE) Application Form

Please complete all sections in capital letters or typing. Athlete 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.


1. Athlete Information
Name:
Male Female Date of Birth:

(dd/mm/yyyy)
Address:
City / Area: Country:
Postcode: Telephone:

(with international code)
Email:
Sport: Sport Discipline:

2. Previous Applications
Have you submitted any previous TUE application(s) to any Anti-Doping Organization for the same condition?
Yes
No
For which substance(s) or method(s)?:
To whom?: When:
Decision
Approved
Not Approved

3. Retroactive Applications
Is this a retroactive application?
Yes
No
If yes, on what date was the treatment started?:
Do any of the following exceptions apply? (Article 4.1 of the ISTUE):
4.1 (a) - You required emergency or urgent treatment of a medical condition.
4.1 (b) -There was insufficient time, opportunity or other exceptional circumstances that prevented you from submitting the TUE application, or having it evaluated, before getting tested.
4.1 (c) - You were not permitted or required to apply in advance for a TUE as per UAE NADA Anti-Doping rules.
4.1 (d) - You are a lower-level athlete who is not under the jurisdiction of an International Federation or National Anti-Doping Organization and were tested.
4.1 (e) - You tested positive after using a substance Out-of-Competition that was only prohibited In-Competition, e.g., S9 glucocorticoids (See Prohibited List)
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, an Athlete 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.

Physician to complete sections 4, 5 and 6.

4. Medical Information (please attach relevant medical documentation)

Diagnosis (Please use the WHO ICD 11 classification if possible):

5. Medication Details
# Prohibited Substance(s)/Method(s) Generic name(s) Dosage Route of Administration Frequency Duration of Treatment
1
2
3
4
5

Evidence confirming the diagnosis must 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. 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 therapeutic use exemption for the prohibited medication


6. Medical Practitioner’s Declaration

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 UAE NADA 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 UAE NADA’s Privacy Policy for more details).
Name:
Medical specialty:
License number: License body:
Address:
City / Area: Country:
Postcode:
Telephone: Fax:
E-mail:
Signature of Medical Practitioner: Date:

7. Athlete’s Declaration

I, _______________________________, certify that the information set out at sections 1, 2, 3 and 7 is accurate and complete. I authorize 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 recognize my TUE; the World Anti-Doping Agency (WADA), who is responsible for ensuring 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 authorize UAE NADA 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.
Athlete’s signature: Date:
Parent’s/Guardian’s signature: Date:

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

TUE Privacy Notice

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 & 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 recognize 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 authorized 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). Consult UAE NADA to which you submit to obtain more details about the processing of your PI.

Your PI will also be uploaded to ADAMS by the ADO who 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)

Please submit the completed form to UAE NADA via Tue@uaenada.ae and keep a copy for your records.
FAIR & LAWFUL PROCESSING

When you sign the Athlete 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 recognized 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 fulfill contractual obligations owed to you, the need to ensure compliance with a legal obligation or a compulsory legal process, or the need to fulfill legitimate interests associated with their activities.2

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 authorization to your physician to release medical information as described in the Athlete 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 fulfill 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 the 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 our 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 10 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 the Intelligence Administrator at UAE NADA for questions or concerns about the processing of your PI. To contact WADA, use privacy@wada-ama.org

Please submit the completed form to UAE NADA via Tue@uaenada.ae and keep a copy for your records.
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