- Complete and maintain (on file in the athletics department) this form and required documentation supporting the medical need for a student-athlete to be treated for ADHD with stimulant medication.
- Submit this form and required documentation to Drug Free Sport in the event the student-athlete tests positive for the banned stimulant (see Medical Exceptions Procedures at www.ncaa.org/drugtesting).
To be completed by the Institution:
Institution Name: _______________________________
Institutional Representative Submitting Form:
- Name: ____________________
- Title: _____________________
- Email: ____________________
- Phone: ___________________
Student-Athlete Name: _________________________
Student-Athlete Date of Birth: ____________________
Prescribed banned medication: ____________________
To be completed by the Student-Athlete's Physician:
Current Treating Physician (print name): ____________________
Specialty: ________________________
Office address: ____________________
Physician signature: _____________________
Date: ____________________
Check off that documentation representing each of the items below is attached to this report:
- ___ Diagnosis.
- ___ Medication(s) and dosage.
- ___ Has considered a non-banned medication alternative.
- ___ Blood pressure and pulse readings and comments.
- ___ Follow-up orders.
- ___ Date of clinical evaluation: ____________________
- ___ Attach written report summary of comprehensive clinical evaluation. Please note that this includes the original clinical notes of the diagnostic evaluation.
The evaluation should include individual and family history, address any indication of mood disorders, substance abuse, and previous history of ADHD treatment, and incorporate the DSM criteria to diagnose ADHD. Attach supporting documentation, such as completed ADHD Rating Scale(s) (e.g., Connors, ASRS, CAARS) scores.
The evaluation can and should be completed by a clinician capable of meeting the requirements detailed above.
DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made, or exam performed, in connection herewith, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided hereunder.