Disability Form.docx
DOCX document 2 MB Posted
- Solicitation number
- RFB 605 2300000799 2
- Issued by
- Johnson County, Kentucky
About this file
This is a Disability Certification Form issued by the Kentucky Transportation Cabinet (KYTC) under the Governor's office in Frankfort, Kentucky. The form serves as a certification mechanism for identifying individuals with qualifying severe disabilities as defined under Kentucky Revised Statutes (KRS) 45A.465 and KRS 12.450. The document requires completion by an employer identifying an applicant's name, date of birth, and disability status, with certification by a qualified third party authorized to determine disability eligibility. The form must be returned to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of the employee's hire date.
The form establishes disability qualification criteria based on federal and state standards, requiring that individuals possess a severe disability or combination of disabilities lasting or expected to last at least twelve months or resulting in death, which prevents engagement in substantial gainful activity. Qualified third parties providing certification must include their credentials, professional contact information, signature, and date of attestation. The form operates as a compliance and documentation tool for disability-related employment programs administered by the Kentucky Transportation Cabinet.
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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 .