Microsoft word - doc_c7ccd459231fa209d193ed6696d906ae_1261472873630_40
THERAPEUTIC USE EXEMPTION (TUE) APPLICATION FORM Please complete all sections in capital letters or type. Incomplete applications will be returned.
I apply for approval from the International Cricket Council’s Therapeutic Use Exemption Committee (the ICC’s TUEC) for the therapeutic use of a Prohibited Substance or Method on the current WADA Prohibited List, a copy of which can be found at www.icc-cricket.com 1. PLAYER INFORMATION
I am a member of the ICC’s International Registered Testing Pool (IRTP):
Please ensure that all telephone/ fax numbers include full Country and Area dialling codes. Where the Player wishes the reply to be sent to his/her representative, please complete the box below, providing the representative’s details and describing his/her relationship to the Player. Player’s Representative Details (where applicable) 2. NOTIFYING MEDICAL PRACTITIONER Please ensure that all telephone/fax numbers include full Country and Area dialling codes. 3. DIAGNOSIS INFORMATION
Medical Examination(s)/Test(s) performed (see note 1):
I have notified my National Cricket Federation’s Chief Medical Officer or Team Doctor of this request.
If Yes, please provide the name of your National Cricket Federation’s Chief Medical Officer or Team Doctor:
4. MEDICATION DETAILS
Treatment Starts (dd/mm/yy) : Treatment finishes (dd/mm/yy):
If a permitted medication can be used to treat the specified medical condition, please provide clinical justification for the intended use of the requested prohibited substance(s)/medication(s) instead of the permitted medication.
In the case of emergency treatment or the treatment of an acute medical condition, or, where, due to exceptional circumstances, there was insufficient time or opportunity to submit an application prior to the treatment (see note 2), please indicate all relevant information to explain the emergency and/or why the TUE application was not submitted prior to treatment:
5. PREVIOUS REQUESTS
Have you made a previous TUE application for the same (or
similar) medication in the last twelve months? If Yes, to which Anti Doping Organisation was the application
submitted? If Yes, when was the application submitted? (dd/mm/yy)
If Yes, what was the result of the application?
Approved (please provide a copy of the TUE Certificate) Not Approved
Has any TUE application that you have previously made (for any
6. MEDICAL PRACTITIONER’S DECLARATION
I, ______________________________________________ certify that the above-mentioned diagnosis and treatment is medically appropriate and that the use of alternative medication containing substances not on the current WADA Prohibited List would be unsatisfactory for this player in this medical condition.
Signature of Medical Practitioner: ________________________________ Date (dd/mm/yy): _____________________
7. PLAYER’S DECLARATION
_______________________________________________ certify that the information contained in sections 1 and 5 herein is
accurate and that I am requesting approval for a Therapeutic Use Exemption (TUE) in connection with a Substance or Method from
authorise the release of personal medical information to the ICC, any ICC contracted doping authority, World Anti-Doping Agency
ADA), and to all other anti-doping authorities (including any applicable NADO or RADO) under the provisions of the WADA
Code. I understand that if I wish to revoke the right of these organisations to obtain my health information, sent either by me or on my
behalf, I must notify my medical practitioner and the ICC’s Anti-Doping Manager in writing.
understand and agree that I should get medical advice from a qualified health professional before taking or stopping any medication
course of treatment in relation to this TUE application. I also understand that the ICC is not providing medical advice to me in
connection with this TUE application and that no decision in this respect is in any way indicative of whether I should or should not foll
ow the medical advice which I have received or will receive with respect to any condition that I may have.
m aware that a TUE application requires the processing (for example transmission, disclosure, use and storage) of all data
pertaining to such application through the Anti-Doping Administration and Management System (ADAMS) to ensure harmonized,
coordinated and effective anti-doping programs for detection, deterrence and prevention of doping. Signing this form indicates that I
have been informed and that I give my express consent to such processing of data.
nderstand and agree that: (a) my application for a TUE will only be considered following the submission (whether through
ADAMS or otherwise) of the present completed application form, as well as all relevant documents related to the application; (b) my
TUE related data will be made accessible through ADAMS to authorized anti-doping authorities, WADA and the ICC’s Therapeutic
Use Exemption Committee; and (c) if a TUE is granted, such TUE and the related information will be stored electronically in ADAMS for a minimum period of 8 years, being the period within which an action can be commenced following an anti-doping
violation under the ICC’s Anti-Doping Code and/or the WADA Code.
understand that my information will only be used for evaluating my TUE request and in the context of possible anti-doping
viol ation 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 on my behalf, 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 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.
The ICC and the ICC’s Therapeutic Use Exemption Committee, WADA, all other anti-doping authorities will not disclose any of my
TUE related information beyond those persons within those organizations with a need to be aware of such information for the
purposes of doping control under the ICC’s Anti-Doping Code and/or the WADA Code.
Having read this waiver and knowing these facts, and in consideration of your reviewing and acting upon my TUE, I and anyone entit led to act on my behalf, hereby release and discharge the ICC, WADA and all other anti-doping authorities (including any appl icable NADO or RADO) and all employees, designees, agents or representatives of those organisations, including those persons
who actually consider and process my TUE, from all claims or liabilities of any kind arising out of or connected in any way with this
TUE application, even if such claims or liability may arise out of negligence or carelessness on the part of the persons or entities named in this waiver. I hereby release the ICC from all claims, demands, liabilities, damages, costs and expense that I may have
arising in connection with the processing of my TUE-related data (whether through ADAMS or otherwise).
Player’s signature: ________________________________ Date (dd/mm/yy): ___________________
If the player is under 18 years of age, a parent or guardian must also sign this application form in addition to the Player:
Parent/Guardian signature: ___________________________ Date (dd/mm/yy): _____________________
Relationship to the Player: _________________________ Please read the additional information and do no t forget to attach sufficient medical information to substantiate the diagnosis and the necessity to use a prohibited substance/method 8. ADDITIONAL INFORMATION Diagnosis must include sufficient medical information Evidence confirming the diagnosis must be attached and forwarded with this application. In those cases where the evidence is not in English, a summary in English should be enclosed. The medical evidence should include a comprehensive, relevant medical history and 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 is requested in support of this application. The minimal requirements for the medical file to be used for the TUE process in the case of asthma has to include the following to reflect current best medical practice: 1. A complete medical history of the relevant medical condition 2. A comprehensive report of the clinical examination with specific focus on the respiratory system 3. A report of spirometry which must at least include the measure of the Forced Expiratory Volume in 1 second (FEV1) or (where spirometry reports are not readily available in the relevant country of region) any report of any other medical test(s) recognised within the field of respiratory medicine as confirming diagnosis of asthma 4. If airways obstruction is present, the spirometry (or other test(s) confirming the diagnosis of asthma) will be repeated after inhalation of short acting Beta-2 Agonist to demonstrate the reversibility of bronchoconstriction 5. In the absence of reversible airways obstruction, a bronchial provocation test is required to establish the presence of 6. Peak flow measurements will not be sufficient 7. Exact name, speciality, address (including telephone, e-mail, fax) of examining physician. More details can be found in the document entitled ‘Medical Information to Support the Decisions of TUECs – Asthma’, which is published by WADA can be found on its website (www.wada-ama.org). In specific circumstances in the International Standard for TUEs, inhaled Salbutamol or Salmeterol for the treatment of asthma does not require a TUE and should therefore be the preferred treatment of such medical conditions. Retrospective grant of a TUE In accordance with Article 184.108.40.206 of the ICC Anti-Doping Code, the player should submit an application as soon as possible after the relevant diagnosis, and, in any event, no less than 30 days before he/she needs the approval (for instance before his/her participation in an International Match (as defined in the ICC Code)). TUE applications submitted within 30 days of which approval is required will be processed as soon as possible. In any event, all TUE applications should be submitted prior to the use of medication containing prohibited substances or the use of prohibited methods except in the following limited cases, where a retroactive TUE approval may be granted retrospectively: 1. emergency treatment or treatment of an acute medical condition was necessary, or 2. due to exceptional circumstances, there was insufficient time or opportunity to submit, or for the ICC’s TUE Committee to consider, an application prior to the player being selected for testing, or 3. when using inhaled Beta-2 Agonists other than Salbutamol or Salmeterol, provided that: (a) the player is not in the International Registered Testing Pool; and (b) that the application is submitted together with the minimal requirements for the medical file as described in Note 1 above. NOTE: Medical emergencies or acute medical situations requiring administration of an otherwise Prohibited Substance or Prohibited Method before an application for a TUE can be made, are uncommon. NOTE: All players in the International Registered Testing Pool must have an approved TUE certificate for inhaled Beta- 2 Agonists other than Salbutamol or Salmeterol in advance of his/her participation in an International Match. Please submit the completed form (keeping a copy for your records) to the ICC’s Anti-Doping Manager using the following contact details:
CURRICULUM VITAE Akademischer Werdegang Medizinstudium an der Christian-Albrechts-Universität Kiel und der University of Sydney, Australia mit Aufenthalten in Bolton und Manchester, UK sowie Le Mans, Promotion (Mucopolysaccharidosis- & lipidosisartige Veränderungen in kultivierten Corneafibroblasten nach Behandlung mit Tiloronanaloga) Ärztin im Praktikum: Henriettenstiftung Hann
RINGWORM INFORMATION AND CONTROL MEASURES What is ringworm? Ringworm is a common skin infection caused by a fungus. Ringworm may affect the skin on the body, scalp, groin area (jock itch), feet (athlete’s foot) or nails. The infection is not related to an infestation of worms. Ringworm occurs when a particular fungus grows and multiples anywhere on the body. Ringworm can affect anyone a