Form SSA-5665-bk Teacher Questionnaire

Form SSA-5665-bk or the "Teacher Questionnaire" is a form issued by the U.S. Social Security Administration.

Download a PDF version of the Form SSA-5665-bk down below or find it on the U.S. Social Security Administration Forms website.

ADVERTISEMENT
Form SSA-5665-BK (06-2018) UF
Discontinue Prior Editions
Page 1 of 10
Social Security Administration
OMB No. 0960-0646
Teacher Questionnaire
Answers For Teachers or Homeschool Teachers About the Questionnaire
One of your current or former students has filed a claim for disability benefits. We need information from
you to help us make a decision. Please complete the enclose questionnaire.
Q. Why Do You Need Information From Me?
A. To decide whether a child qualifies for disability benefits, we use information from both medical and
non-medical sources. Medical sources include doctors and other health care professionals; non-
medical sources include teachers and other people who spend time with the child. Information from
sources who know the child well is important, because a child’s level of functioning at school, at home,
or in the community may affect his or her eligibility. The information you provide about the child’s day-
to-day functioning in school will help us to determine the effects of the child’s impairment(s). It will also
help us to compare this child’s functioning to that of other children the same age who do not have
impairments. We need this information from you even if you have taught (or did teach) the child for only
a short time. Your information is not the only information we will be considering when we decide if the
child qualifies for disability benefits, but it is very important to us.
Q. Is This Request Redundant? We (or Others) Have Already Evaluated This Child Under the
Individuals With Disabilities Education Act (IDEA).
A. The definition of disability in the Social Security Act is entirely separate from the definition of an
"educational disability" in the IDEA. We must determine whether a child's impairment(s) meets the SSA
definition of disability, regardless of the child's standing under the IDEA definition of educational
disability.
Q. I Do Not Think The Child Is Disabled. Should I Complete This Form?
A. Yes. Under Social Security law, we are responsible for deciding whether this child is disabled, and we
will be making our decision based on all of the medical, school, and other information we receive. Your
observations will help us to have a more complete picture of the child's daily functioning and to make a
fair and accurate decision. Your completion of this form does not constitute an endorsement of our
decision.
Q. The Form is Long. Do I Need to Answer Every Question?
A. Not always. The form uses check boxes and multiple choice questions to help you provide specific
information as easily and quickly as possible, so it is not as long as it may appear. We also organized
the form into sections that cover broad domains of functioning. For each section, there is an option to
check one block indicating that you have not observed any limitations in that domain. When you have
not observed any limitations in a domain, you may check that block and move on to the next section.
We appreciate your cooperation, your time, and your effort in completing the questionnaire.
Form SSA-5665-BK (06-2018) UF
Discontinue Prior Editions
Page 1 of 10
Social Security Administration
OMB No. 0960-0646
Teacher Questionnaire
Answers For Teachers or Homeschool Teachers About the Questionnaire
One of your current or former students has filed a claim for disability benefits. We need information from
you to help us make a decision. Please complete the enclose questionnaire.
Q. Why Do You Need Information From Me?
A. To decide whether a child qualifies for disability benefits, we use information from both medical and
non-medical sources. Medical sources include doctors and other health care professionals; non-
medical sources include teachers and other people who spend time with the child. Information from
sources who know the child well is important, because a child’s level of functioning at school, at home,
or in the community may affect his or her eligibility. The information you provide about the child’s day-
to-day functioning in school will help us to determine the effects of the child’s impairment(s). It will also
help us to compare this child’s functioning to that of other children the same age who do not have
impairments. We need this information from you even if you have taught (or did teach) the child for only
a short time. Your information is not the only information we will be considering when we decide if the
child qualifies for disability benefits, but it is very important to us.
Q. Is This Request Redundant? We (or Others) Have Already Evaluated This Child Under the
Individuals With Disabilities Education Act (IDEA).
A. The definition of disability in the Social Security Act is entirely separate from the definition of an
"educational disability" in the IDEA. We must determine whether a child's impairment(s) meets the SSA
definition of disability, regardless of the child's standing under the IDEA definition of educational
disability.
Q. I Do Not Think The Child Is Disabled. Should I Complete This Form?
A. Yes. Under Social Security law, we are responsible for deciding whether this child is disabled, and we
will be making our decision based on all of the medical, school, and other information we receive. Your
observations will help us to have a more complete picture of the child's daily functioning and to make a
fair and accurate decision. Your completion of this form does not constitute an endorsement of our
decision.
Q. The Form is Long. Do I Need to Answer Every Question?
A. Not always. The form uses check boxes and multiple choice questions to help you provide specific
information as easily and quickly as possible, so it is not as long as it may appear. We also organized
the form into sections that cover broad domains of functioning. For each section, there is an option to
check one block indicating that you have not observed any limitations in that domain. When you have
not observed any limitations in a domain, you may check that block and move on to the next section.
We appreciate your cooperation, your time, and your effort in completing the questionnaire.
Form SSA-5665-BK (06-2018) UF
Page 2 of 10
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 223 and 1631(e) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent us from making an accurate and timely decision on the named claimant’s eligibility for benefits.
We will use the information to make a determination of eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To specified business and other community members and Federal, State, and local agencies for
verification of eligibility for benefits under section 1631(e) of the Act; and
2. To Federal, State, or local agencies for administering cash or non-cash income maintenance or
health maintenance programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a person’s
eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089,
entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are available on
our website at www.socialsecurity.gov/foia/bluebook.
Paperwork Reduction Act Statement
- This information collection meets the requirements of 44 U.S.C. §
3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. We estimate that it
will take 40 minutes to read the instructions, gather the facts, and answer the questions. If you have
questions about how to complete the form, contact the Requesting Office; see page 3, upper left corner, for
the name, address, and phone number of the Requesting Office. If you need the address or phone number
for the Requesting Office, you can get it by calling Social Security at 1-800-772-1213 (TTY
1-800-325-0778). SEND THE COMPLETED FORM TO THE REQUESTING OFFICE. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM
Form SSA-5665-BK (06-2018) UF
Discontinue Prior Editions
Page 3 of 10
Social Security Administration
OMB No. 0960-0646
Requesting Office Name and Address
Attach Label or Type in Claimant Name
Teacher Questionnaire
This Form Should Be Completed By The Person(s) Most
Familiar With The Child's Overall Functioning.
Name of School:
1. How long have you known, or did you know, this child?
2.
How often, and for how long, do you, or did you, see this child?
For what subjects:
3. Actual Grade Level:
Current Instructional Levels
Special Ed. Services & Frequency
Reading Level:
Math Level:
Student/Teacher Ratio:
Written Language
Level:
4. Is there, or was there, an unusual degree of absenteeism?
Yes
No
If yes, please explain:
5. Dominant Language:
English
Spanish
Other (please specify)
6. Any other names by which the child is known:
IMPORTANT
Please compare this child's functioning to that of same-aged
children who do not have impairments
If the child is receiving special education services, please be sure to compare his
or her functioning to that of same-aged, unimpaired children who are in regular education.
Form SSA-5665-BK (06-2018) UF
Page 4 of 10
1. Acquiring and Using Information
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section 2.
YES, the child has problems functioning in this domain.
Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has:
1
2
3
4
5
No Problem
A slight problem
An obvious problem
A serious problem
A very serious problem
Rating
1
2
3
4
5
1. Comprehending oral instructions
1
2
3
4
5
2.
Understanding school and content vocabulary
1
2
3
4
5
3.
Reading and comprehending written material
1
2
3
4
5
4.
Comprehending and doing math problems
1
2
3
4
5
5.
Understanding and participating in class discussions
1
2
3
4
5
6. Providing organized oral explanations and adequate descriptions
1
2
3
4
5
7.
Expressing ideas in written form
1
2
3
4
5
8.
Learning new material
1
2
3
4
5
9.
Recalling and applying previously learned material
1
2
3
4
5
10.
Applying problem-solving skills in class discussions
What else can you tell us about the child's problems with these activities? For example, how independent is
the child in doing them? Does the child get extra help, or an unusual degree of structure or support? If so,
what kind and how often? (Continue on the last page if needed.)
Form SSA-5665-BK (06-2018) UF
Page 5 of 10
2. Attending and Completing Tasks
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section 3.
YES, the child has problems functioning in this domain.
Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has
1
2
3
4
5
No Problem
A slight problem
An obvious problem
A serious problem
A very serious problem
Rating
Frequency of Problem
Monthly
Weekly
Daily
Hourly
Paying attention when
1
2
3
4
5
1.
spoken to directly
Monthly
Daily
Weekly
Hourly
1
2
3
4
5
Sustaining attention during
2.
play/sports activities
Monthly
Weekly
Daily
Hourly
Focusing long enough to
1
2
3
4
5
3.
finish assigned activity or task
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Refocusing to task
4.
when necessary
Monthly
Weekly
Daily
Hourly
Carrying out
1
2
3
4
5
5.
single-step instructions
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Carrying out
6.
multi-step instructions
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
7.
Waiting to take turns
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Changing from on activity to
8.
another without being disruptive
Monthly
Daily
Weekly
Hourly
1
2
3
4
5
Organizing own things
9.
or school materials
Monthly
Weekly
Daily
Hourly
Completing class/
1
2
3
4
5
10.
homework assignments
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Completing work accurately
11.
without careless mistakes
Daily
Monthly
Weekly
Hourly
1
2
3
4
5
Working without distracting
12.
self or others
Monthly
Weekly
Daily
Hourly
Working at reasonable pace/
1
2
3
4
5
13.
finishing on time
What else can you tell us about the child's problems with these activities? For example, how independent is
the child in doing them? Does the child get extra help, or an unusual degree of structure or support? If so,
what kind and how often? (Continue on the last page if needed.)

Download Form SSA-5665-bk Teacher Questionnaire

1380 times
Rate
4.6(4.6 / 5) 69 votes
ADVERTISEMENT