Fillable Mv3746 (Wisconsin)

Fill Online, Printable, Fillable, Blank Mv3746 (Wisconsin) Form

Use Fill to complete blank online WISCONSIN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Mv3746 (Wisconsin)

On average this form takes 9 minutes to complete

The Mv3746 (Wisconsin) form is 1 page long and contains:

  • 0 signatures
  • 27 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

BROWSE WISCONSIN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CERTIFICATE OF SUBSTANCE EXAMINATION
BY COMPETENT AUTHORITY
MV3746 4/2019 Ch. 343 Wis. Stats. & Trans. 112 Admin. Code
APPLICANT: After this report has been reviewed, you may be required to le follow-up reports.
We will send you the form at the required time.
Medical Review
Wisconsin Department of Transportation
PO Box 7918, Madison, WI 53707-7918
Telephone: (608) 266-2327
FAX: (608) 267-0518
Email: dmvmedical@dot.wi.gov
Applicant Name Driver License Number
– – –
Street Address Birth Date (m/d/yy)
City, State, ZIP Code (Area Code) Telephone Number
Date Issued (m/d/yy) Examiner Badge Number
License Type
 CDLI  School Bus
 Instruction Permit  Operator  CDL  Passenger Bus
Date of Assessment and/or report must be completed based on an examination conducted within the
past 90 days or since (m/d/yy).
SECTION A Assessment Findings: Please assess this client’s dependency level on alcohol
or controlled substances or other drugs. (check all that apply)
Date of Last Use/Abuse (m/d/yy)
 Irresponsible Use of Alcohol (IU)  Irresponsible Controlled Substance and/or Other Drug Use (IU)
 Irresponsible Use of Alcohol - Borderline (IUB)  Irresponsible Use of a Controlled Substance and/or Other Drug Use
 Suspected Alcohol Dependency  Suspected Controlled Substance Dependency and/or Other Drug
 Alcohol Dependency  Controlled Substance and/or Other Drug Use Dependency
 Alcohol Dependency in Remission  Controlled Substance and/or Other Drug Use Dependency in Remission
Please check drinking pattern and chronicity for alcohol dependency or suspected alcohol dependency ndings.
Drinking Pattern
 Intermittent  Recurrent  Steady
Chronicity
 Early  Moderately Advanced  Far Advanced
SECTION B Treatment Recommended (check all that apply)
 No Treatment
 Driver is to abstain from all mood altering substances
 Outpatient Treatment:
(Regimen) (Date Completed or Expected Completion – m/d/yy)
 Inpatient Treatment:
(Regimen) (Date Completed or Expected Completion – m/d/yy)
 Aftercare:
(Regimen) (Date Completed or Expected Completion – m/d/yy)
SECTION C
Is applicant currently compliant with recommended treatment?
 YES  NO If NO, please explain:
X
(Counselor’s Signature) (Date Signed – m/d/yy)
(Counselor’s Title)
(Area Code – Oce Telephone Number)
(Oce – Street Address, City, State, ZIP Code)
► ◄
► ◄
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Mv3746 (Wisconsin)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document