Disability Form.docx
DOCX document 2 MB Posted
- Solicitation number
- RFB-605-2300000797-2
- Issued by
- Powell County, Kentucky
About this file
This document is a Disability Form issued by the Kentucky Transportation Cabinet (KYTC) to determine whether an applicant has a qualifying severe disability as defined by KRS 45A.465 and KRS 12.450. The form requires the applicant's name, date of birth, and employer name, and asks a qualified third party to certify whether the applicant has a qualifying severe disability. The form must be completed and returned to the KYTC Division of Maintenance, Roadside Environment Branch within 30 days of the employee's hire date.
The document outlines the legal definition of a "disability" and "other individuals with severe disabilities" under Kentucky statutes. It also references the U.S. Department of Labor's criteria for determining a severe disability that lasts at least 12 months or results in death, and prevents the individual from working at a "substantial gainful activity" level. The qualified third party completing the form must provide their name, address, phone, email, signature, and credentials.
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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 .