Disability Form.docx
DOCX document 2 MB Posted
- Attached to
- Janitorial Services: Rowan Co. I-64 Rest Areas
- Solicitation number
- RFB 605 2300000802 2
- Issued by
- Oldham 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 serves as a certification document for employers to verify whether an applicant has a qualifying severe disability as defined under Kentucky Revised Statutes (KRS) 45A.465 and KRS 12.450. Employers complete the form by entering the employer name, applicant name, and date of birth, then indicate whether the individual has or does not have a qualifying severe disability. The form must be completed and returned to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of the employee's hire date.
The form requires certification by a qualified third party—an entity with authority to determine an individual's disabilities—who must provide their name, address, phone number, email, signature, date, and professional credentials. The definition of qualifying severe disability referenced in the form encompasses physical or mental impairments that substantially limit one or more major life activities, have lasted or are expected to last at least twelve months, or result in death, and prevent working at a substantial gainful activity level according to U.S. Department of Labor standards. This certification process appears designed to support employment opportunities for individuals with severe disabilities in connection with KYTC projects or programs.
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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 .