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Drug Notice and Combatant Acknowledgment Form

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Drug Notice and Combatant Acknowledgment Form New York State Department of State State Athletic Commission 123 William Street New York, NY 10038-3804 Telephone: (212) 417-5700 www.dos.ny.gov/athletic Drug Notice and Combatant Acknowledgment Form Combative Sport Professionals are prohibited from using Performance Enhancing Drugs and illicit substances prior to or during a combative sport event, are not to use Nonsteroidal Anti-Inflammatories (NSAIDS) within one week prior to a combative sport event. Combatants are required to disclose at a physical examination conducted at the time of the weigh-in any and all drugs, medications and supplements that a combatant is using. In addition, combatants are not to use any drugs, medications and supplements between the time of the weigh-in physical and the conclusion of the combative sport event unless the combatant has provided notice to the New York State Athletic Commission (NYSAC) and received written approval. Please read the entire notice below regarding NYSAC’s drug policies, complete the acknowledgment form and return it to NYSAC. Please contact NYSAC with any questions (212-417-5700, x3). Nonsteroidal Anti-Inflammatories (NSAIDS): Combatants participating in a combative sport event should avoid the use of non-topical nonsteroidal anti-inflammatories (NSAIDS) within one (1) week of a combative sport event because of a potential increased risk of bleeding. Caution should also be exercised regarding the use of NSAIDS while actively sparring. Use of NSAIDS within one week of a combative sport event may result in cancellation of the match. Drugs that are considered NSAIDS include: ARTHROTEC ASPIRIN (Ecotrin, Empirin, Halfprin, Bayer, Anacin, Zorprin, Excedrin, Bufferin) CHOLINE MAGNESIUM TRISALICYLATE (Trilisate) DICLOFENAC (Voltaren, Voltaren XR, Cataflam, Flector, Voltaren Rapide) DIFLUNISAL (Dolobid) ETODOLAC (Ultradol) FENOPROFEN (Nalfon) FLURBIPROFEN (Ansaid, Froben, Froben SR) IBUPROFEN (Motrin, Advil, Nuprin, Rufen, Neoprofen) INDOMETHACIN (Indocin, Indocin SR, Indocin IV, Indocid) KETOPROFEN (Orudis, Orudis KT, Actron, Oruvail, Orudis SR) KETORALAC (Toradol) MECLOFENAMATE MEFENAMIC ACID (Ponstel, Ponstan) MELOXICAM (Mobic, Mobicox) NABUMETONE (Relafen) NAPROXEN (Naprosyn, Aleve, Anaprox, EC-Naprosyn, Naprelan) OXAPROZIN (Daypro) Illicit Substances and Performance Enhancing Drugs: The use of illicit substances and Performance Enhancing Drugs (PED) presents a grave and growing threat to the integrity of athletic competition within the sports of boxing and mixed martial arts. The use of illicit substances and PEDs in professional boxing is strictly prohibited by the New York State Athletic Commission. All combatants appearing in New York are subject to drug testing for both illicit substances and PEDs. In the event of a positive test, the Commission shall seek administrative license revocation, medical suspension, purse forfeiture, and/or additional fines. In addition to substances which are prohibited by the New York Health Laws and Penal Laws the following substances are prohibited: I. Non-Performance Enhancing Substances • Amphetamines (amphetamine and methamphetamine) • Barbiturates • Benzodiazepines • Cocaine metabolites • Marijuana metabolites • Methadone • Methaqualone • Opiates (codeine and morphine) • Phencyclidine • Propoxyphene DOS-0793 (Rev. 08/16) Page 1 of 2 Drug Notice and Combatant Acknowledgment Form II. Performance Enhancing Substances • 1-Testosterone &/or Metabolite/ 1-Androstendiol/ 1-Androstendione • Bolasterone Metabolite • Boldenone/ Boldione/ Quinbolone Metabolite • Calusterone Metabolite • Clenbuterol • Clostebol Metabolite • Danazol/ Ethisterone &/or Metabolite • Dehydrochloromethyltestosterone (DHCMT) Metabolite • Dihydrotestosterone/ Drostandiol &/or Metabolite • Desoxymethyltestosterone Metabolite • ostanolone &/or Metabolite • Estra-4,9-dien-3,17-dione Metabolite • Fluoxymesterone Metabolite • Formebolone Metabolite • Furazabol Metabolite • 4-Hydroxytestosterone/ Formestane Metabolite • 6a-Methylandrostendione Metabolite • Mestanolone Metabolite • Mesterolone &/or Metabolite • Methandrostenolone (Methandienone, Dianabol) Metabolite • Methandriol &/or Metabolite • Methasterone Metabolite • Methenolone &/or Metabolite • Methylnortestosterone Metabolite • Methyltestosterone Metabolite • Methyl-1-testosterone &/or Metabolite • Mibolerone &/or Metabolite • Nandrolone/ 19-Norandrostendione/ 19-Norandrostendiol Metabolite • Norclostebol Metabolite • Norethandrolone/ Ethylestrenol Metabolite • Oxabolone Metabolite • Oxandrolone &/or Metabolite • Oxymesterone • Oxymetholone Metabolite • Prostanozol Metabolite • Stanozolol Metabolite, • Stenbolone &/or Metabolite • Testolactone Metabolite • Testosterone/ Androstendione/ Androstendiol/ DHEA (T/E Ratio >6) • Trenbolone Metabolite III. Masking Agents: • Probenecid • Epitestosterone (> 200 ng/mL) PROFESSIONAL COMBATANT ACKNOWLEDGMENT: By my signature below, I acknowledge that I have read and understand the above notice. I acknowledge that I am prohibited from using illicit substances and Performance Enhancing Drugs, and will be subject to discipline in the event of such use. I further understand that use of NSAIDS will be a subject of examination and consideration by the NYSAC and its designated ringside physician(s) in determining my medical fitness to compete as a professional combatant in New York State, and that I have a duty to honestly disclose my use of NSAIDs and any other drugs, medications and/or supplements to the examining physician. Combatant Name (Printed): Combatant Signature: Date: DOS-0793 (Rev. 08/16) Page 2 of 2 .
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