Form MV3030V at a glance
What it is: Certificate of Vision Examination by Competent Authority, Wisconsin Department of Transportation, MV3030V.
Who signs: Specialist - Signature and Date - m/d/yyyy: this form must be signed by an MD, DO, OD, PA-C or APNP.
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.
A filled-in Form MV3030V example: an optometrist certifies a driver's vision
How to fill out Form MV3030V, box by box
Applicant Name, Driver License Number, Birth Date and Street Address
Enter the Applicant Name - First, Middle Initial, Last, the Driver License Number and the Birth Date.
Enter the Street Address, City, State, ZIP Code, Email Address and (Area Code) Telephone Number.
License Applied For
License Applied For: Class D, Class M, CDL, School Bus or Passenger.
MV3141 Driver Condition or Behavior Report is enclosed
Yes MV3141 Driver Condition or Behavior Report is enclosed.
Internal WisDOT Use ONLY
Internal WisDOT Use ONLY: Other Type (Behav, Board, Waiver).
Issued by: Date:
Visual Acuity and Temporal Field of Vision In Degrees
Indicate Snellen Chart Figures for Visual Acuity Without RX and With RX, Right Eye 20/ and Left Eye 20/, and the Temporal Field of Vision In Degrees. Minimum Standards see: http://wisconsindmv.gov/vision
Examination within the past 90 days or since
This report must be completed based on an examination conducted within the past 90 days or since:
Progressive eye condition(s)
Does applicant have progressive eye condition(s)? OD OS OU If yes, what?
Traffic signal colors of red, amber and green
Is applicant able to distinguish traffic signal colors of red, amber and green?
Would you recommend
Would you recommend: Corrective lenses, No freeway or interstate highway, Limited radius driving. Miles from home:, Daylight driving ONLY, Other:
Driving evaluation with DMV
Would you recommend a driving evaluation with DMV (knowledge, signs and road test)?
Do you feel the patient is safe to operate the following
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
If applicable, I reviewed the attached Driver Condition or Behavior Report
Additional medical evaluation
Do you recommend any additional medical evaluation?
Specialist - Print Name, Check One and Medical License Number
Enter the Specialist - Print Name, Check One: MD, DO, OD, PA-C or APNP, the Medical License Number, the Office Address, City, State, ZIP Code, the (Area Code) Office Telephone Number and the Patient Exam Date (m/d/yyyy).
More rules for Form MV3030V
Applicant: You may be required to file vision reports on a regular basis.
Incomplete forms will be returned for completion.
Sources
[1] Form MV3030V (4/2019), Certificate of Vision Examination by Competent Authority, Wisconsin Department of Transportation (the Official source link on this page).