Disability Form.docx
DOCX document 2 MB Posted
- Attached to
- Janitorial Services: Boone Co. I-75 Rest Areas
- Solicitation number
- RFB 605 2300000796 2
- Issued by
- Boone 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 to verify whether an applicant or employee has a qualifying severe disability as defined under Kentucky Revised Statutes (KRS) 45A.465 and KRS 12.450. The form requires an employer to document an applicant's name, date of birth, and whether the individual meets the criteria for having a qualifying severe disability. A qualified third party with authority to determine disabilities must complete the certification section, providing their name, address, phone number, email, signature, date, and professional credentials. The completed form must be returned to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of the employee's hire date.
The form establishes disability qualification standards based on federal and state criteria, including the U.S. Department of Labor requirement that an individual must have a severe disability or combination of disabilities lasting or expected to last at least twelve months or resulting in death, and which prevents working at a substantial gainful activity level. Qualifying disabilities include physical or mental impairments that substantially limit major life activities, a record of such impairment, or being regarded as having such an impairment. The Kentucky Transportation Cabinet is designated as an Equal Opportunity Employer with respect to sex, gender identity, and disability status.
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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 .