Lock Haven University of Pennsylvania of Pennsylvania
LockHavenUniversityof Pennsylvania
Athletic Training Phone: (570)484-2878 Fax: (570)484-2220 Email:
Medical Exception ADHD / ADD
The NCAA bans classes of drugs because they can harm student-athletes and can create an unfair advantage in competition. Some legitimate medications contain NCAA banned substances, and student-athletes may need to use these medicines to support their academics and their general health. The NCAA has a procedure to review and approve legitimate use of medications that contain NCAA banned substances through a Medical Exceptions Procedure. The following guidelines will help ensure adequate medical records are on file for student-athletes diagnosed with ADHD in order to request an exception in the event a student-athlete tests positive during NCAA Drug Testing.
Today’s Date: ______
Student-Athlete’s Name______Sport ______Date of Birth ___/___/____
Dear Provider: Your patient is a student-athlete participating in intercollegiate athletics. The NCAA
bans the use of some stimulant medications and requires that the following documentation is submitted to support a request for a medical exception in the case of a positive drug test for such use. For additional information, visit the NCAA Health & Safety website:
Diagnosis: ______
Date of Initial Clinical Evaluation and Diagnosis: ______
Current Medication(s) * and Dosage:
______
*NCAA requires that non-banned medications be considered (if not considered please comment below)
______
______
Monitored blood pressure ______Pulse ______Date ______
Lab Work (if applicable) ______
Patient will follow-up in (circle one): 1 month 3 months 6 months 12 months other______
Required ADHD Evaluation Components:
___ Comprehensive clinical evaluation (using DSM-IV criteria) ATTACH
___ A physical exam
___ Adult ADHD Rating Scale Used: ______ATTACH
(e.g., Adult ADHD Self Report Scale (ASRS), CONNER’s Adult ADHD Report Scale (CAARS)
Copies of the evaluation components above should be submitted with this completed form for the athlete’s college medical record / NCAA. Please feel free to also attach any clinical notes that may help clarify your patient/our athlete’s diagnosis of ADHD/ADD and the need for stimulant medications.
If applicable please submit any additional ADHD evaluation components: (e.g. reporting of ADHD symptoms by other significant individual(s), other psychological testing, previous documentation of ADHD diagnosis, or other components).
Additional notes:
Signature: ______Specialty: ______
Physician/Provider (Printed):______Date: ____/____/____
Office Address: ______Phone #:______
Lock Haven, PA17745