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
- Kentucky
About this file
This document is a Disability Form issued by the Kentucky Transportation Cabinet (KYTC) that is used to determine if an individual has a qualifying severe disability as defined under state law. The form requires the applicant's name, date of birth, and a determination from a qualified third party as to whether the individual has a qualifying disability that constitutes an obstacle to new or continued normal employment. The form outlines the specific criteria used to define a "disability" under state and federal law. The completed form must be returned to the KYTC Division of Maintenance, Roadside Environment Branch within 30 days of the employee's hire date.
The form does not contain any information about a state or local contract opportunity. It is focused solely on the process for evaluating whether an individual has a qualifying severe disability for employment purposes under Kentucky's statutes.
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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 .