The Following Must Be Included in Supporting Documentation

Dear Dr.___________________,

I amss one of your patients, and I am student-athlete at Truman State University. The medication you prescribed for my ADHD is on the NCAA’s list of banned substances. The NCAA allows for medical exceptions for this medication if proper documentation is submitted. This documentation must be in the file prior to any random drug test. A description of the required documentation is listed below. You can read the NCAA guidelines and view a sample letter by visiting www.ncaa.org/health-safety (click on Drug Testing, then Drug Testing Exceptions). I would appreciate if you would write a letter including the appropriate information for my athlete medical file at Truman file. Please send the letter to Michelle Boyd, the head athletic trainer, at the address listed at the end of this letter. If you have any questions, please feel free to contact me.

The following must be included in supporting documentation:

· Student-athlete name.

· Student-athlete date of birth.

· Date of annual follow-up evaluation.

· Results of follow-up evaluation.

· Description of current treatment.

· Clinical evaluation components including:

o Summary of comprehensive clinical evaluation (referencing DSM-IV criteria

o ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores and report

o Blood pressure and pulse readings and comments.

o Note that alternative non-banned medications have been considered, and comments.

o Diagnosis.

o Medication(s) and dosage.

o Follow-up orders.

· Additional ADHD evaluation components if available:

o Report ADHD symptoms by other significant individual(s).

o Psychological testing results.

o Physical exam date and results.

o Laboratory/testing results.

o Summary of previous ADHD diagnosis.

· Documentation from prescribing physician must also include the following:

o Physician name (Printed)

o Office address and contact information.

o Specialty.

o Physician signature and date.

I, _________________________request Dr___________________ to release information regarding my ADHD prescription to Michelle Boyd. This information will be kept in my athletic medical file and will be used for a medical exemption claim in the event I am asked to participate in random drug testing.

_______________________________ ____________________ __________________

Signature date cell phone #

Michelle Boyd, ATC

Send documentation to : Head Athletic Trainer

Truman State University

122 Pershing Building

Kirksville, MO 63501

660-785-7364 (p) 660-785-4166 (f)