Disability Form.docx
DOCX document 2 MB Posted
- Attached to
- Janitorial Services: Clark Co. I-64 Rest Area
- Solicitation number
- RFB 605 2300000787 3
- Issued by
- Casey County, Kentucky
About this file
This is a Disability Form issued by the Kentucky Transportation Cabinet (KYTC) under Governor Andy Beshear's administration, in conjunction with the state's transportation department located in Frankfort, Kentucky. The form serves as a certification document to determine whether an applicant possesses a qualifying severe disability as defined by Kentucky Revised Statutes (KRS) 45A.465 and KRS 12.450. The form requires completion within thirty days of an employee's hire date and must be submitted to the KYTC Division of Maintenance, Roadside Environment Branch.
The form establishes criteria for disability qualification, incorporating three statutory definitions: a physical or mental impairment that substantially limits one or more major life activities; a record of such an impairment; or being regarded as having such an impairment. Additionally, per US Department of Labor standards, individuals must have a severe disability or combination of disabilities lasting at least twelve months or expected to result in death, which prevents engagement in substantial gainful activity. The form requires verification by a qualified third party with authority to determine disabilities, including their name, credentials, address, phone number, email, and signature. The document is designated as an Equal Opportunity Employer position applicable to all genders 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 .