INTERNAIOTNAL KENDO FEDERATION
Therapeutic Use Exemption (TUE) Application Form
Please complete all sections in capital letters or typing. Athlete to complete sections 1, 2, 3 and 7;
Physician to complete sections 4, 5 and 6. Illegible or incomplete applications will be returned andwill need to be re-submitted in legible and complete form.

Athlete Information
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2. Previous Applications
Have you submitted any previous TUE application(s) to any Anti-Doping Organization for the same
condition?
Yes ☐No ☐For which substance(s) or method(s)? Click or tap here to enter text.
To whom? Click or tap here to enter text.
Decision: Approved ☐When? Click or tap here to enter text.

Not approved ☐Page 1 of 7

3. Retroactive ApplicationsIs this a retroactive application?
Yes ☐No ☐If yes, on what date was the treatment started? Click or tap here to enter text.
Do any of the following exceptions apply? (Article 4.1 of the ISTUE):☐ 4.1 (a) - You required emergency or urgent treatment of a medical condition.
☐ 4.1 (b) - There was insufficient time, opportunity or other exceptional circumstances that prevented you fromsubmitting the TUE application, or having it evaluated, before getting tested.
☐ 4.1 (c) - You were not permitted or required to apply in advance for a TUE as per FIK Anti-Doping Rule 2021.
☐ 4.1 (d) - You are a lower-level athlete who is not under the jurisdiction of an International Federation or National
Anti-Doping Organization and were tested.
☐ 4.1 (e) - You tested positive after using a substance Out-of-Competition that was only prohibited In-Competition,e.g., S9 glucocorticoids (See Prohibited List)
Please explain (if necessary, attach further documents)
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☐ Other Retroactive Applications (ISTUE Article 4.3)
In rare and exceptional circumstances notwithstanding any other provision in the ISTUE, an Athlete may apply
for and be granted retroactive approval for their TUE if, considering the purpose of the Code, it would be
manifestly unfair not to grant a retroactive TUE.
In order to apply under Article 4.3, please include a full reasoning and attach all necessary supporting
documentation.
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Physician to complete sections 4, 5 and 6.
4. Medical Information (please attach relevant medical documentation)
Diagnosis (Please use the WHO ICD 11 classification if possible):
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5. Medication Details
Prohibited
Substance(s)/Method(s)Generic name(s)DosageRoute ofAdministration

Frequency

Duration of Treatment

1.
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4.
5.

Evidence confirming the diagnosis must be attached and forwarded with this application. The medical informationmust 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 included when possible. In addition, a shortsummary that includes the diagnosis, key elements of the clinical exams, medical tests and the treatment plan would
be helpful.
If a permitted medication can be used to treat the medical condition, please provide justification for the therapeuticuse exemption for the prohibited medication.
WADA maintains a series of TUE Checklists to assist athletes and physicians in the preparation of complete andthorough TUE applications. These can be accessed by entering the search term “Checklist” on the WADA website:
https://www.wada-ama.org.

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6. Medical Practitioner’s Declaration
I certify that the information in sections 4, 5 and 6 is accurate. I acknowledge and agree that my personal
information may be used by Anti-Doping Organization(s) (ADO) to contact me regarding this TUE application, toverify the professional assessment in connection with the TUE process, or in connection with Anti-Doping Rule
Violation investigations or proceedings. I further acknowledge and agree that my personal information will beuploaded to the Anti-Doping Administration and Management System (ADAMS) for these purposes (see theADAMS Privacy Policy for more details).

Name: Click or tap here to enter text.

Medical specialty: Click or tap here to enter text.

License number: Click or tap here to enter text.

License body: Click or tap here to enter text.

Address: Click or tap here to enter text.

City: Click or tap here to enter text.

Country: Click or tap here to enter text.

Postcode: Click or tap here to enter text.

Telephone: Click or tap here to enter text.

Fax: Click or tap here to enter text.

(with International code)

E-mail: Click or tap here to enter text.

Signature of Medical Practitioner: Click or tap here to enter text.

Date: Click or tap to enter a date.

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7. Athlete’s Declaration
I, Click or tap here to enter text., certify that the information set out at sections 1, 2, 3 and 7 is accurate and complete.
I authorize my physician(s) to release the medical information and records that they deem necessary to evaluate
the merits of my TUE application to the following recipients: the Anti-Doping Organization(s) (ADO) responsiblefor making a decision to grant, reject, or recognize my TUE; the World Anti-Doping Agency (WADA), who isresponsible for ensuring determinations made by ADOs respect the ISTUE; the physicians who are members ofrelevant ADO(s) and WADA TUE Committees (TUECs) who may need to review my application in accordancewith the World Anti-Doping Code and International Standards; and, if needed to assess my application, otherindependent medical, scientific or legal experts.
I further authorize International Kendo Federation to release my complete TUE application, including supporting
medical information and records, to other ADO(s) and WADA for the reasons described above, and I understandthat these recipients may also need to provide my complete application to their TUEC members and relevant
experts to assess my application.
I have read and understood the TUE Privacy Notice (below) explaining how my personal information will beprocessed in connection with my TUE application, and I accept its terms.

Athlete’s signature: Click or tap here to enter text.

Date: Click or tap to enter a date.

Parent’s/Guardian’s signature: Click or tap here to enter text.

Date: Click or tap to enter a date.

(If the Athlete is a Minor or has an impairment preventing them from signing this form, a parent or guardian shallsign on behalf of the Athlete)

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TUE Privacy NoticeThis Notice describes the personal information processing that will occur in connection with your submission of aTUE Application.
TYPES OF PERSONAL INFORMATION (PI)The information provided by you or your physician(s) on the TUE Application Form (including your name,date of birth, contact details, sport and discipline, the diagnosis, medication, and treatment relevant to yourapplication);
Supporting medical information and records provided by you or your physician(s); andAssessments and decisions on your TUE application by ADOs (including WADA) and their TUE
Committees and other TUE experts, including communications with you and your physician(s), relevant
ADOs or support personnel regarding your application.
PURPOSES & USE

Your PI will be used in order to process and evaluate the merits of your TUE application in accordance with theInternational Standard for Therapeutic Use Exemptions. In some instances, it could be used for other purposes inaccordance with the World Anti-Doping Code (Code), the International Standards, and the anti-doping rules ofADOs with authority to test you. This includes:
Results management, in the event of an adverse or atypical finding based on your sample(s) or the Athlete
Biological Passport; andIn rare cases, investigations, or related procedures in the context of a suspected Anti-Doping Rule Violation(ADRV).
TYPES OF RECIPIENTSYour PI, including your medical or health information and records, may be shared with the following:ADO(s) responsible for making a decision to grant, reject, or recognize your TUE, as well as their delegatedthird parties (if any). The decision to grant or deny your TUE application will also be made available toADOs with testing authority and/or results management authority over you;
WADA authorized staff;
Members of the TUE Committees (TUECs) of each relevant ADO and WADA; andOther independent medical, scientific or legal experts, if needed.

Note that due to the sensitivity of TUE information, only a limited number of ADO and WADA staff will receive
access to your application. ADOs (including WADA) must handle your PI in accordance with the International
Standard for the Protection of Privacy and Personal Information (ISPPPI). You may also consult the ADO to which
you submit your TUE application to obtain more details about the processing of your PI.1

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Your PI will also be uploaded to ADAMS by the ADO who receives your application so that it may be accessed byother ADOs and WADA as necessary for the purposes described above. ADAMS is hosted in Canada and isoperated and managed by WADA. For details about ADAMS, and how WADA will process your PI, consult theADAMS Privacy Policy (ADAMS Privacy Policy).
FAIR & LAWFUL PROCESSING
When you sign the Athlete Declaration, you are confirming that you have read and understood this TUE PrivacyNotice. Where appropriate and permitted by applicable law, ADOs and other parties mentioned above may also
consider that this signature confirms your express consent to the PI processing described in this Notice.
Alternatively, ADOs and these other parties may rely upon other grounds recognized in law to process your PI for
the purposes described in this Notice, such as the important public interests served by anti-doping, the need to fulfill
contractual obligations owed to you, the need to ensure compliance with a legal obligation or a compulsory legal
process, or the need to fulfill legitimate interests associated with their activities.2RIGHTS
You have rights with respect to your PI under the ISPPPI, including the right to a copy of your PI and to have yourPI corrected, blocked or deleted in certain circumstances. You may have additional rights under applicable laws,
such as the right to lodge a complaint with a data privacy regulator in your country.
Where the processing of your PI is based on your consent, you can revoke your consent at any time, including theauthorization to your physician to release medical information as described in the Athlete Declaration. To do so,
you must notify your ADO and your physician(s) of your decision. If you withdraw your consent or object to the PI
processing described in this Notice, your TUE will likely be rejected as ADOs will be unable to properly assess it inaccordance with the Code and International Standards.
In rare cases, it may also be necessary for ADOs to continue to process your PI to fulfill obligations under the Codeand the International Standards, despite your objection to such processing or withdrawal of consent (whereapplicable). This includes processing for investigations or proceedings related to ADRV, as well as processing toestablish, exercise or defend against legal claims involving you, WADA and/or an ADO.
SAFEGUARDS
All the information contained in a TUE application, including the supporting medical information and records, andany other information related to the evaluation of a TUE request must be handled in accordance with the principles
of strict medical confidentiality. Physicians who are members of a TUE Committee and any other experts consulted
must be subject to confidentiality agreements.
Under the ISPPPI, ADO staff must also sign confidentiality agreements, and ADOs must implement strong privacy
and security measures to protect your PI. The ISPPPI requires ADOs to apply higher levels of security to TUE
information, because of the sensitivity of this information. You can find information about security in ADAMS by
consulting the response to How is your information protected in ADAMS? in our ADAMS Privacy and Security FAQs.
RETENTION
Your PI will be retained by ADOs (including WADA) for the retention periods described in Annex A of the ISPPPI.
TUE certificates or rejection decisions will be retained for 10 years. TUE application forms and supplementary
medical information will be retained for 12 months from the expiry of the TUE. Incomplete TUE applications will beretained for 12 months.
CONTACT
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Consult FIK at okuura@kendo.or.jp for questions or concerns about the processing of your PI. To contact WADA,
use privacy@wada-ama.org.
Please submit the completed form to [okuura@kendo.or.jp] (keeping a copy for your records).

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