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Japan Anti-Doping Agency (JADA)
Therapeutic Use Exemption (TUE) Application Form
【治療使用特例（TUE）申請書式】
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.
全てのセクションに大文字又はタイプでご記入ください。セクション1、2、3及び7は競技者が、セクション4、5及び6は医師がご記入ください。申請が判読不能又は不備を有する場合には返却されますので、判読可能かつ不備のない書式により再提出してください。

1. Athlete Information

競技者情報 ［※英語記入］

Last Name:First Name(s):

氏（漢字）

名（漢字）
Male:
男性

Female:女性

Date of Birth(dd/mm/yyyy):
生年月日（日 / 月 / 年）(dd) 日/(mm) 月/(yyyy) 年

Address:
住所
City:
市

Country:国
Telephone: (with International code)+
電話番号（国コード含む）

Postcode:
郵便番号
Sport:
競技

Discipline:
種目

必要事項がすべて記載された書式を、次に示された方法により、日本アンチ・ドーピング機構に提出してください。また、自分の記録のために必ず写しを保持してください。
送付先：公益財団法人日本アンチ・ドーピング機構 TUE委員会〒112-0002 東京都文京区小石川 1-12-14 日本生命小石川ビル4階
FAX 03-5801-0944（FAX で申請した場合は、必ず原本を郵送すること）

期日
受付

月日

郵送

月日

追加資料
結果
STRICTLY CONFIDENTIAL
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担当者

FAX

月日

送付月日,

月日

ADAMS

月日

（JADA 記入欄）

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2. Previous Applications

過去の申請 ［※英語記入］

Have you submitted any previous TUE application(s) to any Anti-Doping Organization for the same condition?
過去に同じ条件（健康状態）の TUE 申請をアンチ・ドーピング機関に提出したことはありますか？
Yes
はいNo
いいえ

For which substance(s) or method(s)?
どのような物質又は方法について過去に TUE 申請を提出しましたか？

To whom?
誰に提出しましたか？
Decision: Approved
承認
決定 :When?
いつ提出しましたか？
Not approved
非承認

3. Retroactive Applications

遡及的申請 ［※英語記入］

Is this a retroactive application?
これは遡及的申請ですか？
Yes
はいNo
いいえ

If yes, on what date was the treatment started?
「はい」と答えた場合、治療の開始日はいつですか？
Do any of the following exceptions apply? (Article 4.1 of the ISTUE):
以下の例外のいずれかが適用されますか？（ISTUE 第4.1項）：
4.1 (a) -You required emergency or urgent treatment of a medical condition.
医学的状態の救急又は緊急の治療が必要であった。
4.1 (b) -There was insufﬁcient time, opportunity or other exceptional circumstances that prevented
you from submitting the TUE application, or having it evaluated, before getting tested.
ドーピング検査を受ける前に、TUE 申請を提出する、又はその評価を受けることの妨げとなる、時間や機会の不足、又は他の例外的な事情があった。
（3 ページへ続く）（JADA 記入欄）

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4.1 (c) - You were not permitted or required to apply in advance for a TUE as per Japan
Anti-Doping CODE 2021(p15-p16).
日本アンチ・ドーピング規程 (p15-p16) に基づき、あなたは事前の TUE の申請を許可されず、又は要請されなかった。
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.
あなたは国際競技連盟又は国内アンチ・ドーピング機関の管轄に属さないレベルの競技者であり、検査を受けた。
4.1 (e) - You tested positive after using a substance Out-of-Competition that was only
prohibited In-Competition (e.g. S9 glucocorticoids(See the Prohibited List)).
あなたは競技会（時）においてのみ禁止された物質を競技会外で使用した後、ドーピング検査で陽性の結果を受けた（禁止表のS6から S9を参照。例：S9糖質コルチコイド）。
Please explain (if necessary, attach further documents)
説明してください（必要でしたら関係書類を添付してください）

Other Retroactive Applications (ISTUE Article 4.3)

他の遡及的申請（ISTUE第4.3項）

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 theCode, it would be manifestly unfair not to grant a retroactive TUE.
ISTUE における他の条項にもかかわらず稀で例外的な事情において、世界アンチ・ドーピング規程（CODE）の目的を考慮すると、遡及的な TUE を付与しないことが明らかに不公正である場合には、競技者はその TUE のための遡及的な許可を申請し、付与されることができる。
In order to apply under Article 4.3, please include a full reasoning and attach all necessary supporting
documentation.
第 4.3 項に従い申請を行うために、完全に論拠となる書類を含み、すべての必要な補足文書を添付してください。

（JADA 記入欄）

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Physician to complete sections 4, 5 and 6.
セクション4、5及び6は医師がご記入ください ［※英語記入］

4. Medical Information (please attach relevant medical documentation)
医学的情報（関係する医療文書を添付してください）［※英語記入］
Diagnosis (Please use the WHO ICD classiﬁcation if possible):
診断（可能な限り WHO の国際疾病分類（ICD）を使用してください：5. Medication Details

薬剤の詳細 ［※英語記入］

Prohibited Substance(s)/Method(s)Generic name(s)
禁止物質 / 方法
一般名

Dosage
投与量

Route ofAdministration
投与経路

Frequency
投与頻度

Duration of Treatment
治療期間（予定する治療期間）

1.
2.
3.
4.
5.

Evidence conﬁrming the diagnosis must be attached and forwarded with this application. The medical information must
include a comprehensive medical history and the results of all relevant examinations, laboratory investigations and imagingstudies. Copies of the original reports or letters should be included when possible. In addition, a short summary that includes
the diagnosis, key elements of the clinical exams, medical tests and the treatment plan would be helpful.
この申請には、診断を裏づける証拠（医療情報提供書）を添付し、一緒に送付することが必須です。その医学的証拠には、包括的な病歴及び申請に関係する全ての診察所見、臨床検査及び画像検査の結果が含まれなければなりません。また、可能であれば、病歴の報告又はレターの原本の写しも含めなければなりません。さらに、診断、臨床検査、医学的検査及び治療計画を含めた概略もあればご用意ください。
If a permitted medication can be used to treat the medical condition, please provide justiﬁcation for the therapeutic use
exemption for the prohibited medication.
禁止されていない薬剤で治療可能な場合には、禁止されている薬剤に対する TUE の正当性を示してください。
WADA maintains a series of TUE Checklists to assist athletes and physicians in the preparation of complete and thorough TUE
applications. These can be accessed by entering the search term “Checklist” on the WADA website: https://www.wada-ama.org.
WADAは、競技者及び医師が完全かつ綿密なTUE申請書を作成出来るように一連のTUEチェックリストを管理しています。これらのチェック
リストは、WADAウェブサイト（https://www.wada-ama.org）上で “Checklist” という検索語を入力することにより利用する事ができます。

（JADA 記入欄）

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6. Medical Practitionerʼs Declaration

医師による宣誓書 ［※英語記入］

I certify that the information in sections 4 and 5 above 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,
to verify 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
be uploaded to the Anti-Doping Administration and Management System (ADAMS) for these purposes (see theJapan Anti-Doping Agencyʼs Privacy Policy and the ADAMS Privacy Policy for more details).
上記セクション 4 及び 5 の情報は正確であることを証明いたします。本TUE 申請書に関して、TUE 審査手続きに関連して、又はアンチ・ドーピング規則違反の調査又は手続きに関連して、専門的な評価を検証することを目的に、アンチ・ドーピング機関（ADO）が私に連絡を取るために私の個人情報が使用される可能性があることを認識し、これに合意いたします。
また、上記の目的のために私の個人情報がアンチ・ドーピング管理システム（ADAMS）にアップロードされることについても認識し、これに合意します（詳細は日本アンチ・ドーピング機構個人情報保護に関する基本方針（プライバシー・ポリシー）及び ADAMS プライバシーポリシーを参照してください）。

Name:
氏名
Medical specialty:
専門医療分野License body/License number:
医師免許発行機関 / 医師資格登録番号
Address:
住所
City:
市

Country:国

Postcode:
郵便番号
Telephone: (with International code)
電話番号（国コード含む）

Fax:
ファクシミリE-mail:e メール
Signature of Medical Practitioner:
医師の署名
Date(dd/mm/yyyy):
日付（JADA 記入欄）

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Ver.202101

TUE Privacy Notice

TUE

This Notice describes the personal information processing that will occur in connection with your submissionof a TUE Application.
TUE
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 toyour application);
TUE
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.
ADO WADATUETUETUEADOPURPOSES & USE

Your PI will be used in order to process and evaluate the merits of your TUE application in accordance withthe International Standard for Therapeutic Use Exemptions. In some instances, it could be used for otherpurposes in accordance with the World Anti-Doping Code (Code), the International Standards, and the antidoping rules of ADOs with authority to test you. This includes:TUE
CODE
ADO

Results management, in the event of an adverse or atypical finding based on your sample(s) or theAthlete Biological Passport; andIn rare cases, investigations, or related procedures in the context of a suspected Anti-Doping Rule
Violation (ADRV).
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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 theirdelegated third parties (if any). The decision to grant or deny your TUE application will also be madeavailable to ADOs with testing authority and/or results management authority over you;
TUEADOADOTUE
ADOWADA authorized staff;
WADA
Members of the TUE Committees (TUECs) of each relevant ADO and WADA; andADO

WADA

TUE

TUEC

Other 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 towhich you submit your TUE application to obtain more details about the processing of your PI.
TUE

ADO

WADA

ADO WADAISPPPITUE

ADOYour PI will also be uploaded to ADAMS by the ADO who receives your application so that it may be accessedby other ADOs and WADA as necessary for the purposes described above. ADAMS is hosted in Canada andis operated and managed by WADA. For details about ADAMS, and how WADA will process your PI, consult
the ADAMS Privacy Policy (ADAMS Privacy Policy).
ADO
ADO
ADAMS

WADA

ADAMS

WADA
ADAMS

WADA

ADAMS

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FAIR & LAWFUL PROCESSING

When you sign the Athlete Declaration, you are confirming that you have read and understood this TUE Privacy
Notice. 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 needto fulfill contractual obligations owed to you, the need to ensure compliance with a legal obligation or acompulsory legal process, or the need to fulfill legitimate interests associated with their activities.
TUE
ADO
ADO
ADO

RIGHTS

You have rights with respect to your PI under the ISPPPI, including the right to a copy of your PI and to haveyour PI corrected, blocked or deleted in certain circumstances. You may have additional rights under applicablelaws, such as the right to lodge a complaint with a data privacy regulator in your country.
ISPPPI

Where the processing of your PI is based on your consent, you can revoke your consent at any time, including
the authorization 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 in accordance with the Code and International Standards.

ADO
ADO

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In rare cases, it may also be necessary for ADOs to continue to process your PI to fulfill obligations under theCode and the International Standards, despite your objection to such processing or withdrawal of consent(where applicable). This includes processing for investigations or proceedings related to ADRV, as well asprocessing to establish, exercise or defend against legal claims involving you, WADA and/or an ADO.
CODEADO
WADA

ADO

SAFEGUARDS

All the information contained in a TUE application, including the supporting medical information and records,
and any other information related to the evaluation of a TUE request must be handled in accordance with theprinciples of strict medical confidentiality. Physicians who are members of a TUE Committee and any otherexperts consulted must be subject to confidentiality agreements.
TUE

TUE
TUE

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.
ISPPPI

ADO

ADO
ISPPPI

TUE
ADO

ADAMS
ADAMS

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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
be retained for 12 months.
ISPPPITUEA

ADO WADA

10TUE

12TUE

TUE
12CONTACT

Consult Japan Anti-Doping Agency for questions or concerns about the processing of your PI. To contact WADA,
use privacy@wada-ama.org.
WADA

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