Disability Form.docx
DOCX document 2 MB Posted
- Solicitation number
- RFB 605 2300000779 3
- Issued by
- Spencer County, Kentucky
About this file
This is a Disability Certification Form issued by the Kentucky Transportation Cabinet (KYTC) under the authority of the Governor's Office. The form is used 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 employer completes the form by providing the applicant's name and date of birth, then certifies whether the individual meets the criteria for having a qualifying severe disability. A qualified third party with authority to determine disabilities must sign the form, providing their credentials, contact information, and professional details. 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 defines qualifying disabilities according to both state and federal standards. Under state law, a qualifying severe disability is defined as a physical or mental impairment that substantially limits one or more major life activities, includes a record of such impairment, or involves being regarded as having such impairment. Federal requirements under the US Department of Labor specify that the disability or combination of disabilities must have lasted or be expected to last at least twelve months or result in death, and must prevent the individual from working at a substantial gainful activity level. The form serves as official documentation for employment and contract purposes within the Kentucky Transportation Cabinet system.
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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 .