M-8 Application Form Therapeutic Use Exemption - FIVB

M-8 Application FormTherapeutic Use ExemptionBefore taking into consideration this demand the FIVB requires the athlete's medical file.I apply for approval from FIVB for the therapeutic use of a prohibited substance on the WADA Listof Prohibited Substances and Prohibited Methods, and according to the FIVB Medical Regulationsthat is subject to the Therapeutic Use Exemption application process.1. Athlete Information (please print and complete ALL sections)Surname:Given Names:Male ‡ Female Date of Birth (d/m/y):ZIP and City:Country:Address:Tel. Work:E-mail:National FederationPlease tick the appropriate box:I am part of the FIVB Registered TestingPool for Beach Volleyball or VolleyballTel. Home:Mobile:Fax:PositionDisciplineI am part of a National Anti-Doping OrganizationTesting PoolI am participating in a FIVB or continentalEvent for which a TUE granted pursuantto the FIVB Medical Regulations isrequired¹– Name of FIVB or continental Event:None of the aboveIf athlete with disability, indicate disability:2. Notifying medical practitionerName, qualifications and medical specialty(for example: Dr. AB Cook, MD FRACP, Gastro-enterologist):Address:Tel. Home:Mobile:ZIP and City:Tel. Work:Email:1International Events for which a certificate of Therapeutic Use from FIVB is required are defined as beingthose Events where the FIVB or its Confederations are “the ruling body for the Event or appoint the technicalofficials for the Event”. FIVB Events are listed on the FIVB website: www.fivb.org

3. Medical InformationDiagnosis with sufficient medical information²:Medical examination (s)/test (s) performed:MedicationProhibited Substance (s)Generic nameDose Route FrequencyAnticipated duration of this medication plan:Additional information:Previous TUE applications:YesNoFor which substance?To whom?When?Decision:ApprovedNot approved4. Medical practitioner’s declarationI, certify the above-mentioned substance/s for the above named athlete havebeen/are to be administered as the correct treatment for the above named medical condition. Ifurther certify that the use of alternative medications not on the Prohibited List would beunsatisfactory for the treatment of the above named medical conditions.Specify reasons:Signature and stamp of Medical Practitioner:2Evidence confirming the diagnosis must be attached and forwarded with this application. The medicalevidence should 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 includedwhen possible. Evidence should be as objective as possible in the clinical circumstances and in the case ofnon-demonstrable conditions independent supporting medical opinion will assist this application.