Annual athletic pre-participation physical examination form

NJSIAA STEROID TESTING POLICY
CONSENT TO RANDOM TESTING
In Executive Order 72, issued December 20, 2005, Governor Richard Codey directed the New Jersey Department of Education to work in conjunction with the New Jersey State Interscholastic Athletic Association (NJSIAA) to develop and implement a program of random testing for steroids, of teams and individuals qualifying for championship games. Beginning in the Fall, 2006 sports season, any student-athlete who possesses, distributes, ingests or otherwise uses any of the banned substances on the attached page, without written prescription by a fully-licensed physician, as recognized by the American Medical Association, to treat a medical condition, violates the NJSIAA’s sportsmanship rule, and is subject to NJSIAA penalties, including ineligibility from competition. The NJSIAA will test certain randomly selected individuals and teams that qualify for a state championship tournament or state championship competition for banned substances. The results of all tests shall be considered confidential and shall only be disclosed to the student, his or her parents and his or her school. No student may participate in NJSIAA competition unless the student and the student’s parent/guardian consent to random testing. By signing below, we consent to random testing in accordance with the NJSIAA steroid testing policy. We understand that, if the student or the student’s team qualifies for a state championship tournament or state championship competition, the student may be subject to testing for banned substances. _____________________________ NJSIAA Banned-Drug Classes 2007 - 2008
The term “related compounds” comprises substances that are included in the class by their pharmacological action and/or chemical structure.
No substance belonging to the prohibited class may be used, regardless of whether it is specifically listed as an example.
Many nutritional/dietary supplements contain NJSIAA banned substances. In addition, the U. S. Food and Drug Administration (FDA) does not
strictly regulate the supplement industry; therefore purity and safety of nutritional dietary supplements cannot be guaranteed. Impure
supplements may lead to a positive NJSIAA drug test. The use of supplements is at the student-athlete’s own risk. Student-athletes
should contact their physician or athletic trainer for further information.

The following is a list of banned-drug classes, with examples of banned substances under each class:
(a) Stimulants
(b) Anabolic Agents
(c) Diuretics
(d) Peptide Hormones & Analogues
anabolic steroids
All the respective releasing factors
of the above-mentioned substances
also are banned:
dihydrotestosterone (DHT) hydrochlorothiazide and related compounds
methylenedioxymethamphetamine nandrolone (MDMA, ecstasy) (e) Definitions of positive depends on the following:
1 for caffeine – if the concentration in urine exceeds 15 micrograms/ml 2 for testosterone – if administration of testosterone or use of any other manipulation has the result of increasing the ratio of the total concentration of testosterone to that of epitestosterone in the urine tetrahydrogestrinone (THG) of greater than 6:1, unless there is evidence that this ratio is due to a pipradol physiological or pathological condition prolintane and related compounds
other anabolic agents
Bitter orange) and related compounds
Use of this form is required by N.J.A.C. 6A:16-Programs to Support Student Development

Source: http://www.lakeland.k12.nj.us/cms/lib04/NJ01001488/centricity/domain/8/steriodform.pdf