SCHEDULE 3(b).

World Rugby Handbook

THERAPEUTIC USE EXEMPTION (TUE) APPLICATION FORM World Rugby fax: +353 1 2409 289 Schedule 3b e-mail:TUE@worldrugby.org In accordance with Section 4 of the WADA International Standard for Therapeutic Use Exemptions and World Rugby Regulation 21.4, any Player who wishes to apply for the use of a Prohibited Substances or Prohibited Method to treat a legitimate medical condition must apply to the relevant Therapeutic Use Exemption Committee (TUEC) via their national Union. SECTION A – Player Information - PLEASE PRINT CLEARLY IN CAPITALS First Name: Surname: Date of Birth: / / Gender: Male Female Contact Telephone Number - Mobile: National Union and level: Team/Club: (i.e. Nat 15's Squad/7's/U21's etc) SECTION B – Notifying Medical Practitioner and Medical Information Name: Medical Specialty: Business Address: Telephone Number - Business: Fax Number: Telephone Number - Mobile: Email: Diagnosis with sufficient medical information (see note 1): Has the national Unions Chief Medical Officer / Doctor been notified of this application? Yes No SECTION C - Medical Details Prohibited Substance – Generic Name Dose of Administration Route of Administration Frequency of Administration 1. 2. Intended duration of treatment: Once only Emergency Weeks Months Years If a permitted medication can be used to treat the medical condition, provide clinical justification for requested use of prohibited medication: SECTION D - Medical Practitioner’s Declaration I ,…………………………………………………….… certify that the above mentioned treatment is medically appropriate and that the use of alternative medication not on the Prohibited List would be unsatisfactory for this condition. Signature of Medical Practitioner: Date: / / SECTION E - – Previous or Current TUE Applications Have you submitted any previous TUE application: Yes No What date?: / / If Yes, for what substance/s? TUE Body who provided TUE Decision: TUE Decision: Attach copy of previous TUE application and Certificate of Approval if for same Prohibited Substance Last update: 14 January, 2015 455 STRICTLY CONFIDENTIAL


World Rugby Handbook
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