Disability Form.docx
DOCX document 2 MB Posted
- Attached to
- Janitorial Services: Carter Co. I-64 Rest Areas
- Solicitation number
- RFB 605 2300000803 2
- Issued by
- Calloway County, Kentucky
About this file
This is a Disability 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 by state and federal regulations. The form requires completion of basic applicant information including name and date of birth, as well as employer identification. A qualified third party with authority to determine disabilities must complete and sign the form, providing their credentials, contact information, and professional assessment. 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 determination criteria based on Kentucky Revised Statutes (KRS 45A.465 and KRS 12.450) and U.S. Department of Labor standards. A qualifying severe disability is defined as a physical or mental impairment that substantially limits one or more major life activities, constitutes an obstacle to normal employment, and has lasted or is expected to last at least twelve months or result in death, preventing substantial gainful activity. The form serves as an official certification document and does not include pricing terms, set-asides, or funding requirements, as it functions as an administrative verification tool for disability status rather than a contract solicitation.
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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 .