Teacher Questionnaire; Request for Administrative Information

Forms and Documents

Document Name	Status
Form SSA-5665-BK SSA-5665-BK Form and Instruction	Modified
Form SSA-5666 SSA-5666 Form and Instruction	Modified
Addendum--0646.doc Supplementary Document	2008-07-08
Supporting Statement--0646.doc Supporting Statement A	2008-07-16

IC Document Collections

IC ID	Document Title	Status
9683	SSA-5665-BK Form and Instruction	Modified
183366	SSA-5666 Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0646	ICR Reference No: 200804-0960-003
Status: Historical Active	Previous ICR Reference No: 200801-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Teacher Questionnaire; Request for Administrative Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/11/2008
	Date Received in OIRA: 07/21/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2011	36 Months From Approved	09/30/2008
Responses	1,233,000	0	1,232,000
Time Burden (Hours)	359,750	0	359,417
Cost Burden (Dollars)	0	0	0

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Abstract: If an individual who is claiming disability under Title XVI or Title II is currently or has recently been in an education program, SSA must obtain information about his or her functioning from teachers, instructors, and other education personnel who have the opportunity to observe the individual on a day-to-day basis. Educational programs are an important source of evidence and often provide formal assessment results and other kinds of information from a variety of disciplines.

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Authorizing Statute(s): US Code: 42 USC 1382c Name of Law: null
   US Code: 42 USC 1383b Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 16087	03/26/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 30656	05/28/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
SSA-5665-BK	SSA-5665-BK	Teacher Questionnaire
SSA-5666	SSA-5666	Request for Administrative Information

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,233,000	1,232,000	0	0	1,000	0
Annual Time Burden (Hours)	359,750	359,417	0	0	333	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The increase in the number of respondents is due to the additional use of the forms for the hearings and appeals process by SSA’s Office of Disability Adjudication Review (ODAR). Previously, ODAR had its own form, the HA-68, cleared under OMB Control No. 0960-0721; however, in order to decrease redundancy in the functions of SSA’s forms, SSA requested, and was granted, a discontinuation from OMB for the HA-68 in 1/2008. Now the entire Agency will use the SSA-5665-BK and the SSA-5666 in order to collect this type of information.

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Annual Cost to Federal Government: $6,856,080

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/21/2008

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