Wisconsin Department of Transportation MV3141 - Driver Condition or Behavior Report - Health Care Professional Only

Sep 20, 2026

Wisconsin Department of Transportation form MV3141 collects information about a driver’s condition or behavior to support the Department’s potential action under Wisconsin Statutes section 343.16. The submission explains why the driver’s medical or behavioral status may affect safe operation, with required details and documentation standards. It includes sections for enforcement or private citizens and a separate form for licensed health care professionals to assess medical condition, driving safety, possible license restrictions, and additional evaluation needs. Clear submission instructions and contact details are provided.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Driver Condition or Behavior Report

Good Cause and Submission Information

Driver Details and Identification Fields

Driver Condition and Incident Description

Enforcement Action and Reporting Information

Health Care Professional Section

Medical Assessment and Recommendations

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: Clear Form 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](dmvmedical@dot.wi.gov) Driver Name – First, Middle, Last Driver License Number 1 2 3 4 – 5 6 7 8 – 9 10 11 12 – Birth Date – – M M D D Y Y Y Y State of Issuance 13 14 | | | | --- | --- | | | | | | | --- | --- | --- | --- | | | | | | | --- | --- | --- | --- | | | | | | | --- | --- | --- | --- | | | | | | | --- | --- | --- | --- | | | | | --- | --- | Address, City, State, ZIP Code Driver Condition – Check appropriate boxes. Describe below. Physical Condition Mental/Emotional Condition Blackout, Seizure, Fainting Spell Confused/Disoriented Alcohol/Other Drugs Defective Vision Lack of Knowledge of Traffic Laws 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) | | 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. Clear Form | Driver Name – First, Middle, Last | | | Birth Date | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | – | | | – | | | | | | | | | | M M | | | D D | | | Y Y Y Y | | | | | | Driver License Number
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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 Dri

FAQs

What qualifies as “Good Cause” for Departmental action under section 343.16?

The form states that advanced age alone cannot be considered good cause. Positive driver identification must be established, and license plate number only is not sufficient.

What must be included when describing incidents or conditions that brought the driver to attention?

Provide detailed incidents or conditions, including specific information such as dates, places, and accident reports. The report also requires whether emergency medical personnel were at the scene and any other available information; hearsay or second-hand information is not accepted.

What happens if a health care professional answers “No” to whether the patient can safely operate a motor vehicle?

The form states that a “No” answer results in immediate cancellation of all license classes and endorsements, and the department cannot test a person deemed medically unsafe.

Sep 20, 2026

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