Mv 3030V Form PDF Details

Ensuring the safety of drivers and the public on Wisconsin's roadways involves various measures, one of which is the assessment of a driver's vision. This responsibility falls under the purview of the Wisconsin Department of Transportation, which utilizes the MV3030V form, a Certificate of Vision Examination, as a crucial tool in this process. Created to implement and adhere to the guidelines set forth in Ch. 343 Wis. Stats. and Trans. 112 Admin. Code, this form plays a significant role in determining whether individuals meet the necessary vision standards to hold a driver's license. Applicants might find themselves needing to submit to these vision exams regularly, depending on their circumstances. The form collects comprehensive information, including the applicant's name, operator license number, contact details, and crucially, the results of their vision test – specifying visual acuity and field of vision in each eye, both with and without corrective lenses. Additional sections address whether the applicant can distinguish traffic signal colors and if any progressive eye conditions exist. Notably, the standards differ for non-commercial and commercial drivers, with specific criteria for each laid out on the form. Vision specialists, whose role is advisory in the licensing decision process, are required to complete the report based on an examination conducted within the last 90 days. This detailed assessment ensures that all drivers on Wisconsin roads have met the established vision standards, contributing to the overall safety of the driving community.

QuestionAnswer
Form NameMv 3030V Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmv3030v content form

Form Preview Example

CERTIFICATE OF VISION EXAMINATION BY COMPETENT AUTHORITY

Wisconsin Department of Transportation

MV3030V

1/2013

Ch. 343 Wis. Stats. and Trans. 112 Admin. Code

 

Medical Review

 

 

PO Box 7918, Madison, WI 53707-7918

 

 

 

 

 

APPLICANT: You may be required to ile vision reports on a regular basis.

 

Telephone: (608) 266-2327

We will send you the forms at the time they are required.

 

FAX: (608) 267-0518

 

 

 

 

 

 

 

 

Email: dmvmedical@dot.wi.gov

Incomplete forms will be returned for completion.

 

 

 

 

 

 

 

 

Applicant Name

 

 

Operator 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

 

 

 

 

 

 

 

Minimum standards for non-commercial drivers - 20/100 vision or better in at least (1) one eye and 20° ield of vision

from center of at least (1) one eye. Minimum Wisconsin standards for commercial drivers (applies to drivers grand- fathered or exempted by federal or state law) - 20/60 vision or better in at least (1) one eye and 70° ield of vision from

center of at least (1) one eye. Minimum federal and school and/or passenger endorsement standards - 20/40 vision or better in each eye, 70° ield of vision from center in each eye and ability to distinguish trafic signal colors. Bioptic

lenses may not be used to meet standards. All standards refer to the best vision with or without corrective lenses.

Report must be completed based on an examination conducted within the past 90 days or since:

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.

Indicate Snellen Chart Figures

 

Visual Acuity

Without RX

With RX

Temporal Field of

 

 

Vision In Degrees

 

 

 

 

 

 

 

Right Eye

20/

20/

 

 

 

 

 

 

 

 

 

Left Eye

20/

20/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES NO

1. Does applicant have progressive eye condition(s)? If yes, what?

2. Is applicant able to distinguish trafic signal colors of red, amber and green?

3. Is applicant safe to operate a non-commercial motor vehicle?

 4. Is applicant safe to operate a commercial motor vehicle?

 5. Is applicant safe to operate a passenger and/or school bus?

 6. Re-examination by WisDOT (knowledge, highway signs & road test)

7. Recommended restrictions:  Corrective lenses

 Miles from home: _________________

 Daylight Driving Only

 Other: ____________________________

Comments:

Specialist – Print Name

Check One:  MD

 DO    Medical License Number

 

   OD  PA-C

 APNP

Ofice Address, City, State ZIP Code

 

(Area Code) Ofice Telephone Number

 

 

Patient Examination Date (m/d/yy)

X

 

 

(Specialist - Signature)

Pursuant to s.448.01 and s.449.01 Wis. Statutes and Trans Ch. 112.02 Wis. Admin. Code, this form must be signed by an MD, DO, OD, PA-C or APNP.

How to Edit Mv 3030V Form Online for Free

You could complete Mv 3030V Form easily with the help of our PDFinity® editor. Our editor is constantly developing to present the best user experience possible, and that's due to our dedication to continual development and listening closely to testimonials. Getting underway is effortless! All that you should do is follow the following easy steps down below:

Step 1: Press the orange "Get Form" button above. It's going to open up our tool so you could begin completing your form.

Step 2: Using this advanced PDF tool, you may do more than simply fill out blanks. Express yourself and make your docs look high-quality with customized textual content added, or fine-tune the original input to perfection - all that comes with the capability to add stunning pictures and sign the PDF off.

When it comes to blank fields of this specific document, here's what you should know:

1. The Mv 3030V Form needs specific details to be inserted. Be sure that the following blank fields are filled out:

Part no. 1 of filling out Mv 3030V Form

2. Now that this segment is completed, it's time to insert the necessary specifics in YES NO Does applicant have, Is applicant able to distinguish, Is applicant safe to operate a, Is applicant safe to operate a, Is applicant safe to operate a, Reexamination by WisDOT, Recommended restrictions, Corrective lenses Daylight, Miles from home, Other, Comments, Specialist Print Name, Ofice Address City State ZIP Code, Specialist Signature, and Check One MD DO OD PAC APNP in order to go to the third stage.

Reexamination by WisDOT, Other, and Is applicant safe to operate a inside Mv 3030V Form

People generally get some points wrong while filling out Reexamination by WisDOT in this area. Be sure you review whatever you enter right here.

Step 3: After you've looked over the information you filled in, click on "Done" to conclude your FormsPal process. Right after setting up a7-day free trial account at FormsPal, you will be able to download Mv 3030V Form or email it immediately. The file will also be easily accessible from your personal account menu with your edits. At FormsPal, we do our utmost to guarantee that your information is maintained private.

Mv 3030V Form isn’t the one you’re looking for?

Related Documents