Disability Form.docx
DOCX document 2 MB Posted
- Attached to
- Janitorial Services: Hart Co. I-65 Rest Areas
- Solicitation number
- RFB 605 2300000788 2
- Issued by
- Harrison County, Kentucky
About this file
This is a Disability Form document issued by the Kentucky Transportation Cabinet (KYTC) under Governor Andy Beshear's administration. The form is used to certify whether an applicant or employee has a qualifying severe disability as defined under Kentucky Revised Statutes (KRS) 45A.465 and KRS 12.450, as well as federal standards established by the U.S. Department of Labor. The form requires completion by an employer and submission to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of the employee's hire date. A qualified third party with authority to determine disabilities must verify the disability determination and provide their credentials, contact information, and signature.
The form defines qualifying disabilities as physical or mental impairments that substantially limit one or more major life activities, constitute an obstacle to normal employment, and have lasted or are expected to last at least twelve months or result in death while preventing substantial gainful activity. The certification process requires documentation from qualified third parties, including their name, address, phone number, email, signature, date, and professional credentials. The form includes checkboxes to indicate whether the individual does or does not have a qualifying severe disability. As an Equal Opportunity Employer, KYTC uses this form as part of its compliance with disability employment provisions.
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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 .