Wisconsin Department of Transportation Medical Review
P.O. Box 7918, Madison, WI 53707-7918
Telephone: (608) 266-2327 FAX: (608) 267-0518
Email: dmvmedical@dot.wi.gov
CERTIFICATE OF VISION EXAMINATION BY COMPETENT AUTHORITY
Wisconsin Department of Transportation
MV3030V/T579 4/2019 Ch. 343 Wis. Stats. and Trans. 112 Admin. Code
APPLICANT: You may be required to le vision reports on a regular basis. We will send you the forms at the time they are required.
Incomplete forms will be returned for completion.
This report must be completed based on an examination conducted within the past 90 days or since:
YES NO
1.
2.
3.
4.
5.
6.
7.
Does applicant have progressive eye condition(s)? OD OS OU If yes, what?
Is applicant able to distinguish trac signal colors of red, amber and green?
Would you recommend:
Corrective lenses
No freeway or interstate highway
Limited radius driving. Miles from home:
Daylight driving ONLY
Other:
Would you recommend a driving evaluation with DMV (knowledge, signs and road test)?
Do you feel the patient is safe to operate the following: (any recommendations are strictly advisory)
Non-Commercial Vehicle
Commercial Vehicle
School and/or Passenger Bus
If applicable, I reviewed the attached Driver Condition or Behavior Report
Do you recommend any additional medical evaluation?
Comments:
Applicant Name – First, Middle Initial, Last
Driver License Number
1 2 3 4 5 6 7 8 9 1 0 11 12 13 14
Birth Date
M M D D Y Y Y Y
Street Address City State ZIP Code
Email Address (Area Code) Telephone Number
Yes MV3141 Driver Condition or Behavior Report is enclosed
Internal WisDOT Use ONLY Other Type
Behav
Board
Waiver
Issued by:
License Applied For
Class D Class M CDL School Bus Passenger
Date:
Minimum Standards see: http://wisconsindmv.gov/vision
VISION SPECIALIST: The Secretary of the Department of
Transportation is, by statute, responsible for the decision of
driver licensing. Your report will be advisory in determining
eligibility.
Indicate Snellen Chart Figures
Visual
Acuity
Without RX With RX
Temporal Field of
Vision In Degrees
Right Eye 20/ 20/
Left Eye 20/ 20/
Specialist – Print Name Check One:
MD DO
Medical License Number
OD PA-C APNP
Oce Address, City, State, ZIP Code (Area Code) Oce Telephone Number
X
Patient Exam Date (m/d/yyyy)
(Specialist – Signature) (Date – m/d/yyyy)
Pursuant to s.448.01 and s.449.01 Wis. Statutes and Trans Ch. 112.02 Wis. Admin. Code, this form must be signed by an MD, DO, OD, PA-C or APNP.
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