Disability Form.docx
DOCX document 2 MB Posted
- Attached to
- Janitorial Services: Rowan Co. I-64 Rest Areas
- Solicitation number
- RFB-605-2300000802-2
- Issued by
- Rowan County, Kentucky
About this file
This document is a Disability Form from the Kentucky Transportation Cabinet (KYTC) that outlines the requirements for individuals to qualify as having a "severe disability" under Kentucky state law. The form defines a severe disability as a physical or mental impairment that substantially limits one or more major life activities and has lasted or is expected to last at least 12 months. The form must be completed by a qualified third party, such as a medical professional, to verify the individual's disability status. The completed form must be returned to the KYTC Division of Maintenance, Roadside Environment Branch within 30 days of the employee's hire date.
The form specifies the legal definitions of "other individuals with severe disabilities" and "disability" per Kentucky Revised Statutes. It also references the U.S. Department of Labor's criteria for determining a severe disability that prevents an individual from working at a "substantial gainful activity" level. Employers must use this form to document the disability status of applicants or employees seeking to qualify under the state's preference for contracting with businesses owned by or employing individuals with severe disabilities.
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Text version
Andy Beshear
GOVERNOR
TRANSPORTATION CABINET
200 Mero Street Frankfort, Kentucky 40601
Jim Gray
SECRETARY
[Type here]
Employer Name: ______________________________________________________________
Applicant Name: _______________________________ Date of Birth: ___________________
☐ Yes, this person has a qualifying severe disability.
☐ No, this person does not have a qualifying severe disability.
Per KRS 45A.465 - "Other individuals with severe disabilities" means an individual or class of individuals with a disability, other than blindness, that constitutes an obstacle to new or continued normal employment.
Per KRS 12.450 - "Disability" means, with respect to an individual:
(a) A physical or mental impairment that substantially limits one (1) or more of the major life activities of the individual;
(b) A record of such an impairment; or
(c) Being regarded as having such an impairment.
Per US Department of Labor - individuals must have a severe disability (or combination of disabilities) that has lasted, or is expected to last, at least 12 months or result in death, and which prevents working at a "substantial gainful activity" level.
Qualified Third Party (entity with authority to determine an individual’s disabilities)
Name: _____________________________________
Address: ___________________________________
Phone: ____________________________________
Email: _____________________________________
Signature: ___________________________________ Date: ______________
Credentials: _________________________________
Return Form to KYTC Division of Maintenance, Roadside Environment Branch within thirty (30) days of employee’s hire date.
KYTC | TRANSPORTATION.KY.GOV
An Equal Opportunity Employer M/F/D image1.png image2.png
File details come from the government source that posted it. Updated .