Teacher Questionnaire;
Request for Administrative Information
Revision of a currently approved collection
No
Regular
12/09/2020
Requested
Previously Approved
36 Months From Approved
01/31/2021
337,725
404,564
209,952
251,178
0
0
When determining the effects of a
child’s impairment(s), SSA obtains information about the child’s
functioning from teachers, parents, and others who have the
opportunity to observe the child on a daily basis. SSA uses Forms
SSA-5665-BK and SSA-5666 to make one-time requests for teacher
reports; results of formal testing; therapy progress notes;
individualized education programs; and other records of a child’s
educational aptitude and achievement. Forms SSA-5665-BK and
SSA-5666 are available electronically to school and training
program administrators on SSA’s website. State Disability
Determination Services (DDS) or SSA may send a request for
completion of the SSA-5665-BK to a child’s local school
administrative office or training program, which refers the request
to the child’s teacher(s), who then accesses the form through the
link. The teacher(s) forwards the completed SSA-5665-BK to the
school’s or training program’s administrative office, which uploads
it to SSA’s Electronic Records Express (ERE) system. The DDS or SSA
may send a request for completion of the SSA 5666 and copies of the
child’s school records to the central or local administrative
school office, depending on which office maintains the child’s
individual academic records. The administrative office or training
program can also upload the child’s records via ERE. Although the
SSA-5665-BK and SSA 5666 are available for online completion, some
teachers and school personnel may print and manually complete the
forms, then fax or mail them to the requesting DDS or SSA office.
Respondents are teachers and other education personnel.
US Code:
42
USC 1382c Name of Law: Social Security Act
US Code: 42
USC 1383b Name of Law: Social Security Act
When we last cleared this IC in
2017, the burden was 251,178 hours. However, we are currently
reporting a burden of 209,952 hours. This change stems from a
decrease in the number of responses from 404,564 to 337,725. There
is no change to the burden time per response. Although the number
of responses changed, SSA did not take any actions to cause this
change. These figures represent current Management Information
data.
$4,199,840
No
Yes
Yes
No
No
No
No
Faye Lipsky 410 965-8783
faye.lipsky@ssa.gov
No
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Form SSA-5666 SSA-5666 (Electronic)
Supporting Statement - 0646.docx
SSA-5666 (Electronic)