Disability Form.docx
DOCX document 2 MB Posted
- Solicitation number
- RFB 605 2300000804 2
- Issued by
- Boone County, Kentucky
About this file
This is a Disability Certification Form issued by the Kentucky Transportation Cabinet (KYTC) under Governor Andy Beshear's administration. The form serves as a documentation tool for employers to certify whether an applicant or employee has a qualifying severe disability as defined under state and federal regulations. The form requires basic information including the employer name, applicant name, and date of birth, followed by a certification checkbox indicating whether the individual has a qualifying severe disability. The form must be completed by a qualified third party with authority to determine disabilities and returned to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of the employee's hire date.
The form incorporates definitions from Kentucky Revised Statutes (KRS 45A.465 and KRS 12.450) and the U.S. Department of Labor, establishing that qualifying disabilities must constitute an obstacle to normal employment, substantially limit major life activities, and have lasted or be expected to last at least twelve months or result in death. The qualified third party completing the certification must provide their credentials, contact information, and signature. This documentation is used to support diversity and equal employment opportunity initiatives within the Transportation Cabinet, which identifies itself as an Equal Opportunity Employer for minorities, females, and individuals with disabilities.
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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 .