DECLARATION OF USE
Glucocorticosteroids administered by intraarticular, periarticular, peritendinous, epidural,
intradermal and inhalation routes 



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
Salbutamol (maximum 1600 micrograms over 24 hours) /Salmeterol by inhalation
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Please complete in CAPITAL LETTERS or typing.
1. Athlete Information
Family Name: ___________________________
Gender:
Male

Female

First Name: _________________________
Date of Birth (d/m/y):___________________
Address: ___________________________________________________________________________
City /Postcode:________________________________________
Phone: ______________________________
Country:_________________
E-mail: _______________________________
Sport/Discipline:________________________
2.
Medical Practicioner Information
Family Name: ___________________________
First Name: _________________________
Medical Speciality:_________________________________________________________________
Address: ___________________________________________________________________________
City /Postcode:________________________________________
Phone: ______________________________
STRICTLY CONFIDENTIAL
Country:_________________
E-mail: _______________________________
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3. Diagnosis and Medical Information
Diagnosis and description of the necessity of Use: _________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Medical Examination(s) / Test (s) performed / Additional Information: _________________________
__________________________________________________________________________________
__________________________________________________________________________________
4. Medication details
Substance
/Generic Name
Dosage
Route of
administration

Frequency

Expected duration of treatment:
Once only

Or duration (week(s), month(s)…..:______________________




Emergency
Starting date
(d/m/y)
5. Athlete’s declaration
I, _______________________________________, certify that the information provided above is
accurate. I authorize the release of personal medical information to ITTF, as well to WADA authorized
staff, the WADA TUEC (Therapeutic Use Exemption Committee), and to other authorized Anti-Doping
Organisations (ADO) under the provisions of the World Anti-Doping Code. This information will only
be used for legitimate anti-doping purposes. I understand that if I ever wish 1) to 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
practicioner and ITTF in writing of that fact.
I consent and agree that this declaration of Use requires the creation of my profile and the
processing of data pertaining to such declaration in WADA Doping Control Clearinghouse (ADAMS)
and/or any other authorized ADOs similar system to ensure harmonization and coordination of antidoping programmes.
Date:_____________________________
Athlete’s Signature: _____________________
Date:_____________________________
Parent’s/ Guardian’s____________________
Signature (if the athlete is a minor)
STRICTLY CONFIDENTIAL
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Please submit the completed form to
Ms. Alison Burchell
International Table Tennis Federation
Chemin De la Roche 11, 1020 Renens, Switzerland
Phone : +41 21 340 70 90
Fax :
+41 21 340 70 99
E-mail : burchell@ittf.com
and keep a copy for your records.
ITTF will acknowledge that your Declaration of Use has been received
IMPORTANT
THE ATHLETE MUST ALSO DECLARE THE USE OF THIS MEDICATION ON THE DOPING CONTROL
FORM, EVERY TIME HE/SHE IS TESTED !
STRICTLY CONFIDENTIAL
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