Disability Form.docx
DOCX document 2 MB Posted
- Solicitation number
- RFB 605 2300000783 3
- Issued by
- Wayne County, Kentucky
About this file
This is a disability certification form issued by the Kentucky Transportation Cabinet (KYTC) under Governor Andy Beshear's administration. The form is used to document and 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 completion by an employer and submission to the KYTC Division of Maintenance, Roadside Environment Branch within thirty days of an employee's hire date. The document includes fields for employer name, applicant name, date of birth, and a certification checkbox indicating whether the individual has a qualifying severe disability.
The form references three disability standards: KRS 45A.465 defines "other individuals with severe disabilities" as those with disabilities other than blindness that constitute an obstacle to new or continued normal employment; KRS 12.450 defines "disability" as a physical or mental impairment substantially limiting major life activities, a record of such impairment, or being regarded as having such impairment; and the U.S. Department of Labor standard requires that disabilities have lasted or are expected to last at least twelve months, result in death, or prevent working at a substantial gainful activity level. Certification must be completed by a qualified third party with authority to determine an individual's disabilities, and the form requires documentation of that third party's credentials, contact information, and signature. The KYTC operates as an Equal Opportunity Employer.
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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 .