Information Collection

Teacher Questionnaire 20 CFR 416.924a, 20 CFR 404.1520

IC 9683 under ICR 200801-0960-001 · OMB 0960-0646.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0646 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-5665-BK Teacher Questionnaire 20 CFR 416.924a, 20 CFR 404.1520 Form and Instruction
SSA-5665-BK Teacher Questionnaire SSA-5665-BK Mock-up.pdf Form and Instruction
SSA-5665-BK Original.pdf Teacher Questionnaire IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Teacher Questionnaire 20 CFR 416.924a, 20 CFR 404.1520	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1520 20 CFR 416.924a

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-5665-BK	Teacher Questionnaire	SSA-5665-BK Mock-up.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 617,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	617,000	-495,000	1,112,000
Annual IC Time Burden (Hours)	205,667	-118,750	324,417
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Teacher Questionnaire	SSA-5665-BK Original.pdf	01/03/2008

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.