《治疗用药豁免申请表》由会员分享，可在线阅读，更多相关《治疗用药豁免申请表（3页珍藏版）》请在金锄头文库上搜索。
1、治疗用药豁免申请表 Therapeutic Use Exemptions（TUE） 请打印或用正楷填写/Please complete all sections in capital letters or typing 1. 运动员信息 Athlete Information 姓名： 性别： 出生日期： Name Sex Date of Birth 注册单位： 代表单位： Registration Representation 注册证号码： 身份证号码： Registration Number ID card Number 项目： 小项位置： Sport Discipline/Position
2、 通讯地址： 邮编： Address Postcode 联系电话（附国际代码） ： 传真: Tel. (with international code) Fax 手机： 电子邮件： Mobile E-mail 所属国际或国家体育协会名称： International or National Sport Organization 如果运动员是残疾人，请申明残疾情况： If athlete with disability, indicate disability 2. 医务人员信息 Medical practitioners information 姓名 性别 年龄 Name Sex Age 职务
3、： 职称： Position Title 医学科别： 执业医师证书编号 Medical Division Medical practitioner certificate number 工作单位 Work Unit 联系电话： 手机： Tel. Mobile 电子邮件： E-mail 诊断： Diagnosis with sufficient medical information 3. 禁用物质或方法详情 Medication details 禁用物质名称 Prohibited substance(s) Generic name 使用方式 Dose 使用剂量 Route 使用频次 Frequ
4、ency 1 2 3 计划使用时间 Intended duration of treatment 从 年 月 日至 年 月 日 赛内使用： In Competition Use 赛外使用： Out of Competition Use 以前是否申请过治疗用药豁免： 是 否 Have you submitted any previous TUE application? 如果是，日期： When? 批准单位： To whom? 审批结果（请附上以前治疗用药豁免审批结果） ： Decision (Please attach prior TUE application result) 如果有允许使用
5、的物质或方法可以用于治疗该运动员的伤病，请说明申请使用禁用物质或方法的理由： If there is any injury that can justify the treatment to the athlete with the prohibited substance or method, please specify the reason for the use of the prohibited substance or the method. 4.如有其它说明请提出，并附上充分证实该诊断和使用禁用物质必要性的医学资料 If there is any other declaratio
6、n, please present here. Medical file satisfactorily proving the diagnosis and the necessity of the use of the prohibited substance or the method should be attached. 5. 医务人员和运动员声明 Declaration of Medical practitioner and Athlete 我保证运动员使用上述违禁物质对于其上述的伤病是正确的治疗。 I certify that the above-mentioned treatmen
7、t is medically appropriate and that the use of alternative medication not on the prohibited list would be unsatisfactory for this condition. 医务人员签名： 日期： Medical practitioners signature Date 我保证在 1项中关于我的信息是准确的，并确认我正在要求批准使用兴奋剂目录中的禁用物质或方法。 我同意将我个人的医学信息提交国家体育总局反兴奋剂中心治疗用药豁免委员会以及治疗用药豁免委员会 认为合适的其他专家。 I cer
8、tify that the information under column 1 is accurate and that I am requesting approval to use a Substance or Method from the WADA Prohibited List. I authorize the release of personal medical information to China Anti-Doping Agency (CHINADA) as well as to WADA staff, to the WADA TUEC (Therapeutic Use
9、 Exemption Committee) and to other Anti-Doping Organization (ADO) under the provisions of the Code. I understand that if I ever wish to revoke the right of these organizations to obtain my health information on my behalf, I must notify my medical practitioner and CHINADA in writing of that fact. 运动员
10、签名： 日期： Athletes signature Date 6、运动员注册单位或代表单位意见（盖章） Declaration of the Athletes Registration or representation team (confirmed by official stamp) 运动员赛外申请治疗用药豁免，由运动员注册单位同意；运动员赛内申请治疗用药豁免，由运动员代表单 位同意。协议积记分或双记分运动员，涉及的单位均应同意。 Athletes application for out-of-competition use of prohibited substances or me
11、thod has to be agreed by the registration team of the Athlete. Athletes application for in-competition use of prohibited substances or method has to be agreed by the representation team of the Athlete. TUE application for by exchanged Athlete has to be agreed by all teams involved. 7、不完整的申请将被退回并需要重新提交。 Incomplete Applications will be returned and will need to be resubmitted.
