FIVB_M-3_2011

M-3
HEALTH CERTIFICATE
Certificat de Santé
THE PLAYER YOU ARE EXAMINING WILL PLAY UNDER DEMANDING AND STRESSFUL CONDITIONS INCLUDING HEAT, HIGH
HUMIDITY, EXPOSURE TO INTENSES SUNLIGHT, HIGH PHYSICAL EXERTIONS, WHICH CAN LAST TILL 3 HOURS.
Le joueur que vous examinez sera exposé à des conditions difficiles et stressantes comprenant la chaleur, un taux d'humidité élevé, une longue
exposition au soleil, un effort physique intense, pouvant durer jusqu'à 3 heures.
THIS FORM MUST BE HANDED OVER DURING THE PRELIMINARY TEAM INQUIRY
Ce formulaire doit être remis lors de l'enquête préliminaire avec les équipes
FAMILY NAME / Nom:
NAME / Prénom:
BIRTH DATE / Date de naissance:
COUNTRY / Pays:
HEREWITH I CONFIRM THAT TO THE BEST OF OUR KNOWLEDGE AND AFTER PROFESSIONAL MEDICAL EXAMINATION OF THE
PLAYER HEREIN MENTIONED, HE/SHE IS IN GOOD HEALTH, ABLE TO TRAVEL BY ANY MEANS OF TRANSPORTATION AND PLAY IN
VOLLEYBALL COMPETITIONS.
Le soussigné confirme en toute connaissance de cause qu’après avoir procédé à un examen médical approfondi du joueur ci-dessus, il/elle jouit
d’une bonne santé, peut voyager avec n’importe quel moyen de transport et participer à des compétitions de Volleyball.
I, AS A PARTICIPANT IN A FIVB EVENT, HEREBY ACKNOWLEDGE AND AGREE AS FOLLOWS:
1. I have had an opportunity to review the FIVB Medical Regulations, including the Anti-Doping Rules.
2. I consent and agree to comply with and be bound by all of the provisions of the FIVB Anti-Doping Rules, including but not limited to, all
amendments to the Anti-Doping Rules and all International Standards incorporated in the Anti-Doping Rules.
3. I consent and agree to the creation of my profile in WADA Doping Control Clearing House (ADAMS), as requested under WADA Code to
which the FIVB, as an IF, is a signatory, and/or any other authorized National Anti-Doping Organizations (NADOs) similar system under the
FIVB’s agreement for the sharing of information, and to the entry on my doping control, Whereabouts and Therapeutic Use Exemptions
related data in such systems.
4. I also acknowledge and agree that any dispute arising out of a decision made pursuant to the FIVB Anti-Doping Rules, after exhaustion of the
process expressly provided for in the FIVB Anti-Doping Rules, may be appealed exclusively as provided in Article 12 of the FIVB Anti-Doping
Rules to the Court of Arbitration for Sport ("CAS") as an appellate body for final and binding arbitration.
5. I acknowledge and agree that the decisions of CAS shall be final and enforceable, and that I will not bring any claim, arbitration, lawsuit or
litigation in any other court or tribunal.
6. I have read and understand this Acknowledgement and Agreement.
LE SOUSSIGNE, PARTICIPANT A UN EVENEMENT FIVB, PREND CONNAISSANCE ET ACCEPTE :
1. J’ai eu l’opportunité de lire le Règlement Médical de la FIVB, y compris le Règlement Antidopage.
2. J’accepte et respecte d’être lié à toutes les dispositions du Règlement Antidopage de la FIVB, incluant mais ne se limitant pas uniquement
aux modifications du Règlement et à tous les standards internationaux confirmés dans ledit Règlement Antidopage.
3. Je consens et accepte la création de mon profil dans le système AMA Clearing House (ADAMS), comme demandé dans le Code de l’AMA à
laquelle la FIVB, comme IF, est signataire, et/ou dans n’importe quel autre système similaire autorisé d’Organisations Nationales Antidopage
(ONAD), sous accord, avec la FIVB, pour le partage de l’information et à l’entrée de mon contrôle antidopage, des informations de localisation
et des Autorisations d’usage à des fins thérapeutiques dans de tels systèmes.
4. Je prends également connaissance et accepte que toute dispute provenant d’une décision prise selon le Règlement Antidopage de la FIVB
puisse, après avoir épuisé toutes les procédures prévues à cet effet dans le Règlement Antidopage de la FIVB, être envoyée en appel,
comme mentionné exclusivement dans l’Article 12 du Règlement Antidopage de la FIVB, au Tribunal Arbitral du Sport ("TAS"), organisme
d’appel pour décider d’un arbitrage final.
5. Je prends connaissance et accepte que les décisions du TAS sont sans appel et exécutoires et que je ne ferai aucune réclamation, arbitrage,
procès ou litige auprès de toute autre cour ou tribunal.
6. J’ai lu, compris et pris connaissance de ce document.
PLAYER SIGNATURE
Signature du joueur
DOCTOR NAME
Nom du médecin
MEDICAL EXAMINATION DATE / Date de l’examen médical:
DOCTOR SIGNATURE
Signature du médecin
D/j
M/m
Y/a
FIVB Official form M-3 / 2014
M-8 Application Form
Therapeutic Use Exemption
Before 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 List
of Prohibited Substances and Prohibited Methods, and according to the FIVB Medical Regulations
that 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. Home:
Tel. Work:
Mobile:
E-mail:
Fax:
National Federation
Position
Discipline
Please tick the appropriate box:
I am part of the FIVB Registered Testing
Pool for Beach Volleyball or Volleyball
I am part of a National Anti-Doping Organization
Testing Pool
I am participating in a FIVB or continental
Event for which a TUE granted pursuant
to the FIVB Medical Regulations is
required¹
– Name of FIVB or continental Event:
None of the above
If athlete with disability, indicate disability:
2. Notifying medical practitioner
Name, qualifications and medical specialty
(for example: Dr. AB Cook, MD FRACP, Gastro-enterologist):
Address:
ZIP and City:
Tel. Home:
Tel. Work:
Mobile:
Email:
1
International Events for which a certificate of Therapeutic Use from FIVB is required are defined as being
those Events where the FIVB or its Confederations are “the ruling body for the Event or appoint the technical
officials for the Event”. FIVB Events are listed on the FIVB website: www.fivb.org
3. Medical Information
Diagnosis with sufficient medical information²:
Medical examination (s)/test (s) performed:
Medication
Prohibited Substance (s)
Generic name
Dose
Route
Frequency
Anticipated duration of this medication plan:
Additional information:
Previous TUE applications:
Yes
No
For which substance?
To whom?
When?
Decision:
Approved
Not approved
4. Medical practitioner’s declaration
I,
certify the above-mentioned substance/s for the above named athlete have
been/are to be administered as the correct treatment for the above named medical condition. I
further certify that the use of alternative medications not on the Prohibited List would be
unsatisfactory for the treatment of the above named medical conditions.
Specify reasons:
Signature and stamp of Medical Practitioner:
2
Evidence confirming the diagnosis must be attached and forwarded with this application. The medical
evidence 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 included
when possible. Evidence should be as objective as possible in the clinical circumstances and in the case of
non-demonstrable conditions independent supporting medical opinion will assist this application.
5. Athlete’s declaration
I,
certify that the information under 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 the FIVB and other responsible Anti-Doping Organization (ADO) as
well as to WADA authorized staff, to the WADA TUEC (Therapeutic Use Exemption Committee)
and to other ADO TUECs and authorized staff that may have a right to this information under the
provisions of the Code.
I understand that my information will only be used for evaluating my TUE request and in the context
of possible anti-doping violation investigations and procedures. I understand that if I ever wish to (1)
obtain more information about the use of my information; (2) exercise my right of access and
correction or (3) revoke the right of these organizations to obtain my health information, I must
notify my medical practitioner and FIVB in writing of that fact. I understand and agree that it may be
necessary for TUE-related information submitted prior to revoking my consent to be retained for the
sole purpose of establishing a possible anti-doping rule violation, where this is required by the Code.
I understand that if I believe that my personal information is not used in conformity with this consent
and the International Standard for the Protection of Privacy and Personal Information I can file a
complaint exclusively to WADA or CAS.
Signature of the athlete:
Date:
Parent’s/Guardian’s Signature:
(If the athlete is a minor or has a disability preventing him/her to sign this form, a parent or guardian shall sign together with or on behalf of the
athlete).
Incomplete and/or illegible Applications will be returned and will need to be resubmitted!
F E D E R A T I O N I N T E R NA T I O N A L E D E V O L L E Y B A L L
Edouard-Sandoz 2-4, 1006 Lausanne/Switzerland ; Tel.: +41 21 345 35 35, Fax: +41 21 345 35 45
E-mail: [email protected]