WADA - Checklist for Therapeutic Use Exemption (TUE) Application - Acute Mountain Sickness

© WADA - World Anti-Doping Program Checklist for a TUE Application – Acute Mountain Sickness – Version 1.0 – January 2026 Page 1/1 Checklist for Therapeutic Use Exemption (TUE) Application: Acute Mountain Sickness

Prohibited Substance: Acetazolamide

This Checklist is to guide the athlete and their physician on the requirements for a TUE application that will allow the TUE Committee to assess whether the relevant International Standard for Therapeutic Exemptions (ISTUE) Criteria are met.

Please note that the completed TUE application form alone is not sufficient; supporting documents MUST be provided. A completed application and checklist DO NOT guarantee the granting of a TUE. Conversely, in some situations an acceptable application may not include every element on the checklist.

☐ TUE Application form must include: ☐ All sections completed legibly ☐ All information submitted in [language(s) as per ADO preferences] ☐ A signature from the applying physician ☐ The Athlete’s signature ☐ Medical report should include details of: ☐ Full travel itinerary, including trekking or travel dates, altitudes, and flights ☐ Diagnosis (e.g. Acute Mountain Sickness, Hypoxia induced illness, etc.) ☐ Medication dose and duration, including planned date of commencement and discontinuation

☐ Relevant medical history including, if present:

1. A previous history of altitude illness with medical documentation of the event ii. Details of any medical co-morbidities which increase the risk of AMS iii. Reasons for rapid ascent above 2500m, preventing appropriate acclimatization to altitu ☐ Additional information (if necessary) ☐ [As per ADO specifications]

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