ITU Paratriathlon Classification Rules and Regulations 2012 Edition ...

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APPENDIX 4: VISUAL IMPAIRMENT CERTIFICATE International Triathlon Union (ITU) MEDICAL DIAGNOSTICS FORM FOR ATHLETES WITH VISUAL IMPAIRMENT Please complete the form in capital letters The form must be completed in capital letters by a registered Ophthalmologist. The information on this form is used to determine the athlete’s eligibility to compete in accordance with ITU classification rules. Incomplete applications, or failure to have this form completed, may result in the athlete not being classified and preventing them from competing at that event. It is mandatory that the athlete submits a copy of this form and all relevant documentation to the Chief Classifier at classification 1. ATHLETE INFORMATION Surname: ........................................... Given Names: ......................... Female Male Date of Birth (d/m/y): ………………………………….. Address: ............................................................................................... City: ................................................ Country: ................................ Email: ................................................................................................... 2. MEDICAL INFORMATION Current Diagnosis with Sufficient Medical Information (see note 1) ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… Age of onset: ………... Anticipated future procedure(s): ………………………........................................................ 38
Glasses: YES / NO Contact Lenses: YES / NO Prosthesis: YES / NO Correction: R:……….L:………. R: ……….L:……….……. LEFT / RIGHT Eye Medications ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 3. ASSESSMENT RESULTS Visual Acuity RE LE With Correction Without Correction Type of correction: ………………………………………………………………………. Measurement Method: ………………………………………………………………….. Visual Field (see note 2) Please attach visual field map RE LE Degrees (diameter) The athlete evaluation is based on the assessment of visual acuity in the eye with better visual acuity whilst wearing best optical correction using spectacles or contact lenses. IBSA Sport Class (Refer page 3 for details: B1 B2 B3 Other Relevant Medical History ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 4. OPHTHALMOLOGIST DECLARATION I certify that ……………………………………………………………………. meets the ITU minimal eligibility criteria of IBSA sport class B3 as outlined on page 3 I certify that there is no contra-indication for this individual to compete at a competitive level. in ITU sport. Name(PRINT):……………………………………………………............................................. Qualifications: Registration number: …………………………………………………………………………… Address: E-mail: …………………………………………. 39
Page 1 and 2: ITU Paratriathlon Classification Ru
Page 3 and 4: 8. CLASSIFIER EDUCATION AND CERTIFI
Page 5 and 6: .) An ITU paratriathlon classifier
Page 7 and 8: .) All classifying personnel must a
Page 9 and 10: a.) A Classification Panel will con
Page 11 and 12: It is expected that this will occur
Page 13 and 14: .) If the paratriathlete intentiona
Page 15 and 16: (i) a change in the degree of impai
Page 17 and 18: a.) The Classification Appeal Body
Page 19 and 20: (ii) sports specific and/or technic
Page 22 and 23: 10. MEDICAL DEFINITIONS Locomotor D
Page 24 and 25: arms slightly impaired or missing b
Page 26 and 27: 12. PARATRIATHLON CATEGORIES - ILLU
Page 28 and 29: TRI 5 - Moderate leg impairment 23
Page 30 and 31: 3 - Moderate impairment; able to ac
Page 32 and 33: 15. DETERMINING BASE LINE SCORES: T
Page 34 and 35: APPENDIX 1: CONSENT FOR CLASSIFICAT
Page 36 and 37: 1 2 3 4 5 6 7 36
Page 40 and 41: Signature of Ophthalmologist: .....
Page 42 and 43: Brief Description of Impairment and
Page 44 and 45: 5. Delivery of certification course
Page 46 and 47: Table 1: ITU Paratriathlon Classifi
Page 48 and 49: DECISION OF THE CLASSIFICATION PROT

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