Disability Form.docx
DOCX document 2 MB Posted
- Attached to
- Janitorial Services: Oldham Co. I-71 Rest Areas
- Solicitation number
- RFB 605 2300000781 3
- Issued by
- Morgan County, Kentucky
About this file
This is a Disability Determination Form issued by the Kentucky Transportation Cabinet (KYTC) under the Office of the Governor. The form serves as a certification document for employers to verify whether an applicant has a qualifying severe disability in accordance with Kentucky Revised Statutes (KRS) 45A.465 and KRS 12.450. The form requires the employer name, applicant name, and date of birth, followed by a certification statement indicating whether the individual meets the criteria for a qualifying severe disability. The completed form must be submitted to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of the employee's hire date.
The form defines disability according to state and federal standards, requiring that a disability be a physical or mental impairment substantially limiting one or more major life activities, have a documented record of impairment, or be regarded as such an impairment. Additionally, per U.S. Department of Labor standards, the disability must have lasted or be expected to last at least twelve months, result in death, or prevent the individual from working at a substantial gainful activity level. The form requires certification from a qualified third party with authority to determine disabilities, including their name, address, phone, email, signature, date, and credentials. No pricing, funding, or contract terms are specified in this form, as it functions as an administrative certification document rather than a procurement solicitation.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .