Disability Form.docx
DOCX document 2 MB Posted
- Solicitation number
- RFB 605 2300000801 2
- Issued by
- Oldham County, Kentucky
About this file
This is a Disability Form document from the Kentucky Transportation Cabinet (KYTC), under the Governor's Office, designed to certify whether an individual applicant has a qualifying severe disability. The form requires completion by an employer and submission to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of an employee's hire date. The form serves as a verification mechanism for disability status determinations used in employment and contracting contexts.
The form establishes criteria for disability qualification based on three statutory frameworks: Kentucky Revised Statute (KRS) 45A.465 defines severe disability as any impairment other than blindness that constitutes an obstacle to normal employment; KRS 12.450 defines 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 the U.S. Department of Labor standard requires that the disability or combination of disabilities must have lasted or be expected to last at least twelve months, result in death, or prevent working at a substantial gainful activity level. Certification must be provided by a qualified third party with authority to determine disability status, including their name, credentials, address, phone, email, and signature. The form includes checkboxes to indicate whether the individual does or does not have a qualifying severe disability.
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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 .