Fillable Mv3141 Driver Condition or Behavior Report

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Mv3141 Driver Condition or Behavior Report

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  • 13 check-boxes
  • 48 other fields

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DRIVER CONDITION OR BEHAVIOR REPORT
Wisconsin Department of Transportation
MV3141 (1) 4/2019
LAW ENFORCEMENT OR PRIVATE CITIZEN Complete this side only
The following information is submitted for consideration as “Good Cause” for
Departmental action as authorized under section 343.16 Wisconsin Statutes.
Advanced age alone, cannot be considered as good cause. Positive driver
identification must be established. License plate number only is not sufficient.
This information may be subject to Wisconsin's Open Records Law.
Submit to:
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
Driver Name – First, Middle, Last
Birth Date
–
–
M
M
D
D
Y
Y
Y
Y
Driver License Number
–
–
–
1
2
3
4
5
6
7
8
9
10
11
12
13
14
State of Issuance
Address, City, State, ZIP Code
Driver Condition – Check appropriate boxes. Describe below.
Physical Condition
Mental/Emotional Condition
Blackout, Seizure, Fainting Spell
Lack of Knowledge of Traffic Laws
Confused/Disoriented
Alcohol/Other Drugs
Defective Vision
Obstructing Traffic
Type of Enforcement Action Taken
Incident Date
Time
Report Date (m/d/yy)
Describe in detail incidents or conditions, which brought this driver to your attention. Give specific information such as
dates, places, accident reports, were Emergency Medical Personnel at the scene and all other available information to
support the Department’s action. DMV will not accept hearsay or second-hand information.
Print Name
(Area Code) Telephone Number
Address, City, State, ZIP Code
X
(Signature) (Date m/d/yy)
If this report is being completed by private citizens or family members, the full name, address and signature of a second or additional
person who can verify the above information is REQUIRED. A signature verifies the information to be true and correct.
Print Name
(Area Code) Telephone Number
Address, City, State, ZIP Code
X
(Signature) (Date m/d/yy)
Clear Form
DRIVER CONDITION OR BEHAVIOR REPORT
Wisconsin Department of Transportation
MV3141 (2) 4/2019
HEALTH CARE PROFESSIONAL ONLY
Only MD, DO, OD, PA-C or APNP complete this side
This information is not subject to Wisconsin’s Open Records Law; it is, however, available to the driver upon request.
Driver Name – First, Middle, Last
Birth Date
–
–
M
M
D
D
Y
Y
Y
Y
Driver License Number
–
–
–
1
2
3
4
5
6
7
8
9
10
11
12
13
14
State of Issuance
Date of Examination
Address, City, State, ZIP Code
Describe in detail patient’s current medical condition(s) and diagnosis. Give specific information to support the Department’s
action.
YES
NO
1.
Is this patient able to safely operate a motor vehicle at this time?
A “No” answer will result in immediate cancellation of all license classes and endorsements.
The department cannot test a person who is deemed medically unsafe.
2.
If the answer to #1 is “Yes”, do you recommend a complete re-examination of patient’s driving ability
(knowledge, sign and skills tests)?
3.
If the answer to #1 is "Yes," do you recommend that the driver's license be restricted? Check all that apply.
Continuous oxygen use No freeway or interstate highway
Daylight driving only Corrective lenses
Drive only miles from home
4.
Do you recommend any additional medical evaluation?
Print Name
Medical License Number
–
1
2
3
4
5
6
7
8
(Area Code) Telephone Number
Mailing Address, City, State, ZIP Code
Signature of MD, DO, OD, PA-C or APNP
X
(Signature) (Date m/d/yy)
Clear Form
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Completed 10 July 2020

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