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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. 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Advanced age alone, cannot be considered as good cause. Positive driver identification must be established. License plate number only is not sufficient.  \nThis information may be subject to Wisconsin's Open Records Law.  \nSubmit to:  \nClear Form  \nWisconsin Department of Transportation Medical Review  \nP.O. Box 7918  \nMadison, WI 53707-7918  \nTelephone: (608) 266-2327  \nFAX: (608) 267-0518  \nEmail: [dmvmedical@dot.wi.gov](dmvmedical@dot.wi.gov)  \nDriver Name – First, Middle, Last  \nDriver License Number  \n1  \n2  \n3  \n4  \n–  \n5  \n6  \n7  \n8  \n–  \n9 10 11 12  \n–  \nBirth Date  \n– –  \nM M D D Y Y Y Y  \nState of Issuance  \n13 14  \n\n|  |  |\n| --- | --- |\n\n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n|  |  |\n| --- | --- |\n\nAddress, City, State, ZIP Code  \nDriver Condition – Check appropriate boxes. Describe below.  Physical Condition  \n Mental/Emotional Condition  \n Blackout, Seizure, Fainting Spell  \n Confused/Disoriented  Alcohol/Other Drugs  Defective Vision  \n Lack of Knowledge of Traffic Laws  Obstructing Traffic  \n\n| Type of Enforcement Action Taken | Incident Date | Time | Report Date (m/d/yy) |\n| --- | --- | --- | --- |\n\nDescribe 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.  \n| Print Name |  | (Area Code) Telephone Number |\n| --- | --- | --- |\n| Address, City, State, ZIP Code | X |  |\n|  | (Signature) (Date m/d/yy) |  |\n\nIf 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.  \n\n| Print Name |  | (Area Code) Telephone Number |\n| --- | --- | --- |\n| Address, City, State, ZIP Code | X |  |\n|  | (Signature) (Date m/d/yy) |  |\n\nDRIVER CONDITION OR BEHAVIOR REPORT  \nWisconsin Department of Transportation MV3141 (2) 4/2019  \nHEALTH CARE PROFESSIONAL ONLY  \nOnly MD, DO, OD, PA-C or APNP complete this side  \nThis information is not subject to Wisconsin’s Open Records Law; it is, however, available to the driver upon request.  \nClear Form  \n| Driver Name – First, Middle, Last |  |  | Birth Date |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  | – |  |  | – |  |  |  |  |  |\n|  |  |  | M M |  |  | D D |  |  | Y Y Y Y |  |  |  |  |\n| Driver License Number\u003Cbr>– – –\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>1 2 3 4 5 6 7 8 9 10 11 12 13 14 | State of Issuance | Date of Examination |  |  |  |  |  |  |  |  |  |  |  |\n\nAddress, City, State, ZIP Code  \nDescribe in detail patient’s current medical condition(s) and diagnosis. Give specific information to support the Department’s action.  \nYES NO  \n  1. Is this patient able to safely operate a motor vehicle at this time?  \nA “No” answer will result in immediate cancellation of all license classes and endorsements.  \nThe department cannot test a person who is deemed medically unsafe.  \n  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)?  \n  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  \n Daylight driving only  Corrective lenses  \n Dri","cbCaimiLgplJsJDP","https://ap.wps.com/l/cbCaimiLgplJsJDP","pdf",1378599,"English","# Driver Condition or Behavior Report\n## Good Cause and Submission Information\n## Driver Details and Identification Fields\n## Driver Condition and Incident Description\n## Enforcement Action and Reporting Information\n## Health Care Professional Section\n## Medical Assessment and Recommendations","[{\"question\":\"What qualifies as “Good Cause” for Departmental action under section 343.16?\",\"answer\":\"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.\"},{\"question\":\"What must be included when describing incidents or conditions that brought the driver to attention?\",\"answer\":\"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.\"},{\"question\":\"What happens if a health care professional answers “No” to whether the patient can safely operate a motor vehicle?\",\"answer\":\"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.\"}]","Wisconsin Department of Transportation MV3141 - Driver Condition or Behavior Report - Health Care Professional Only | PDF",1789872045]