Change Worksheet

Explanation Change Worksheet

SSA-5665-BK, Teacher Questionnaire

SSA-5666, Request for Administrative Information

OMB # 0960-0646

The SSA-5665-BK and the SSA-5666 were originally intended for use by the disability determination services (DDSs) to obtain information for Title XVI childhood disability claims from teachers and schools. A classroom or home-school teacher(s) completes the Teacher Questionnaire by filling check blocks in response to age-related sets of questions about a child’s day-to-day functioning at school and in the classroom. The administrative office (at either the school level or the school district level) that is responsible for maintaining children’s academic records completes the Request for Administrative Information in a particular child’s claim.

The Office of Disability Adjudication and Review (ODAR) requested that the two forms be made available to ODAR adjudicators for obtaining evidence needed in children’s cases adjudicated in the DDSs. ODAR personnel would use the forms when they are either missing from a file, or there is need for more recent information about a child’s functioning. ODAR currently uses form HA-68, OMB No. 0960-0721 to collect this information. In order to eliminate duplicative SSA forms, ODAR has agreed to use the SSA-5665 and SSA-5666 in place of the HA-68. We have prepared a discontinuation request for OMB No. 0960-0721.

We are also making clarifying in changes in the cover sheet of the SSA-5665 to indicate that Home-school teachers also complete this form, and we will no longer include the SSN on the SSA-5666 we send to schools.

Proposed changes:

• To make the SSA-5665-BK and the SSA-5666 available to ODAR representatives, we are requesting a minor change in the first page of each form. In the upper left corner of each form, there is currently a block in which the DDS provides its name and address. We request that the block be changed from, “DDS Name and Address,” to show “Requesting Office Name and Address.” We will increase the burden by 60,000 responses comparable to ODAR’s usage of the HA-68 (OMB-0960-0721).

• SSA-5665-BK, Cover Sheet. We will change the heading of the cover sheet to show:

TEACHER QUESTIONNAIRE

ANSWERS FOR CLASSROOM OR HOME-SCHOOL TEACHERS

ABOUT THE QUESTIONNAIRE

• SSA-5666, page 1, box in upper right corner. We will delete “AND SSN” from the heading of this box (per order from the Office of the General Counsel), and delete the two dashes at the bottom of the box which have been used to separate the numbers of the child’s SSN.