Disability Form.docx
DOCX document 2 MB Posted
- Attached to
- Janitorial Services: Bullitt Co. Welcome Center
- Solicitation number
- RFB 605 2700000053 1
- Issued by
- Kentucky
About this file
This is a Disability Determination Form from the Kentucky Transportation Cabinet (KYTC), Governor's Office, used to certify whether applicants or employees have qualifying severe disabilities. The form requires an employer to identify the applicant's name and date of birth, then make a determination as to whether the individual meets the criteria for a qualifying severe disability as defined under Kentucky Revised Statutes (KRS) 45A.465 and KRS 12.450. A qualified third party with appropriate credentials and authority to determine disabilities must complete the certification, providing their name, address, phone number, email, signature, date, and credentials. The 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 eligibility standards based on federal and state definitions, requiring that an individual have a physical or mental impairment substantially limiting one or more major life activities, either as a current condition, a record of such impairment, or being regarded as having such impairment. Under US Department of Labor standards, the disability 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 KYTC operates as an Equal Opportunity Employer and uses this documentation to identify individuals with severe disabilities who may qualify for specific employment or contracting opportunities.
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Other files
| File | Type | Posted |
|---|---|---|
| Final_RFB_605_2700000053_1_SO_FORM.PDF | ||
| How to Submit an Online Response - March 2023.pdf |
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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 .