Disability Form.docx
DOCX document 2 MB Posted
- Solicitation number
- RFB 605 2400000292 1
- Issued by
- Breathitt County, Kentucky
About this file
This is a Disability Determination Form issued by the Kentucky Transportation Cabinet (KYTC) under Governor Andy Beshear's administration. The form is used to document whether an applicant or employee has a qualifying severe disability as defined under Kentucky Revised Statutes (KRS) 45A.465 and KRS 12.450. The form requires completion by an employer and submission by a qualified third party with authority to determine disabilities. The completed form must be returned to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of the employee's hire date.
The form defines qualifying severe 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, consistent with U.S. Department of Labor standards. A qualified third party, such as a medical professional or certified disability evaluation entity, must verify the disability determination by providing credentials, signature, contact information, and address on the form. The Kentucky Transportation Cabinet identifies itself as an equal opportunity employer with respect to gender, disability status, and other protected classifications.
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Other files
| File | Type | Posted |
|---|---|---|
| Annual Affidavit for Bidders, Offerors and Contractors - Jan 2023.docx | DOCX document | |
| Final_RFB_605_2400000292_1_SO_FORM.PDF | ||
| How to Submit an Online Response - March 2023.pdf |
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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 .