Disability Form.docx
DOCX document 2 MB Posted
- Solicitation number
- RFB 605 2300000797 2
- Issued by
- Morgan County, Kentucky
About this file
This is a Disability Form issued by the Kentucky Transportation Cabinet (KYTC) under Governor Andy Beshear's administration for certifying individuals with qualifying severe disabilities. The form is used to document whether an applicant or employee has a severe disability that meets specific statutory criteria. The form requires an employer to provide the applicant's name, date of birth, and employer information, along with a certification checkbox indicating whether the person has a qualifying severe disability or not. The form must be completed by a qualified third party with authority to determine an individual's disabilities, including their credentials, contact information, and signature. 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 establishes disability eligibility based on three legal definitions: Kentucky Revised Statutes 45A.465 defining "other individuals with severe disabilities" as those whose disability constitutes an obstacle to new or continued normal employment; KRS 12.450 defining "disability" as a physical or mental impairment substantially limiting major life activities, a record of such impairment, or being regarded as having such impairment; and U.S. Department of Labor criteria requiring that the severe disability (or combination of disabilities) has lasted or is expected to last at least twelve months or result in death, and prevents working at a "substantial gainful activity" level. The KYTC is designated as an Equal Opportunity Employer regarding race, sex, and disability status.
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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 .