Supporting Statement
Teacher Questionnaire, Form SSA-5665-BK
Request for Administrative Information, Form SSA-5666
20 CFR Section 416.924(a)(2)
OMB No. 0960-0646
A. Justification
Section 1614(a)(3)(C) of the Social Security Act (the Act), as amended by Public Law 104-19, requires that the Social Security Administration (SSA) apply a statutory definition of disability for children (individuals under the age of 18) claiming Supplemental Security Income (SSI) benefits based on disability. Section 1633 of the Act allows the Commissioner of Social Security to make appropriate or necessary administrative and other arrangements to carry out the functions of the Agency under this Title. 20 CFR 416.924(a) of the Code of Federal Regulations requires that SSA must consider all relevant evidence in the case record when determining whether a child is disabled under Title XVI of the Act (initial, reconsideration, or continuing disability determination). This may include medical evidence, school records, and employment history – that is, information from people who know the child and can provide information about the child’s functioning. 20 CFR 416.924(a)(2) requires that, when determining the effects of the child’s impairment(s), SSA must obtain information about the child’s functioning from teachers, parents, and others who have the opportunity to observe the child on a day-to-day basis. Education programs are an important source of evidence and often provide formal assessment results and other kinds of information from a variety of disciplines. Evidence obtained from education programs varies a great deal, however, in format, content, reliability, and usefulness. The need exists, therefore, for an information collection instrument that will assure a degree of uniformity and consistency in the quantity and quality of information received about children’s impairment-related limitations; hence the need for these forms.
Forms SSA-5665-BK and SSA-5666 are used by SSA and the State Disability Determination Services (DDSs) (which make disability determinations for SSA under Title XVI of the Act) to obtain information about a child’s functioning. Form SSA‑5665-BK requests information from teachers based on their personal observations of the child; Form SSA-5666 requests information from existing school records (for example, comprehensive triennial evaluations, Individualized Education Programs). Educators and other school professionals (counselors, nurses, et al.) can provide the specific, reliable information we need on how the child functions in activities in the school setting, and how the child has functioned in school over the last 12 months. This information gives us an insight into the child’s day-to-day functioning, which is critical in determining childhood disability.
The DDSs and SSA evaluate such information from both the child’s teacher(s) and the school records whenever a child’s functioning is an issue in a disability case at any stage of the disability sequential evaluation process.
For a working-age child, the DDS and SSA need information about how the child functions in work-related activities (e.g., how well the child understands instructions, follows instructions, sticks with a task). In most cases, the SSA-5665-BK is sufficient to obtain adequate information about a working-age child’s day-to-day functioning. However, in a limited number of cases, the DDS or SSA may request similar information about such a child’s activities from sources other than teachers; e.g., vocational counselors. There is no national form or set format for such requests, but DDSs and SSA will gather the same kinds of information about these children that the SSA-5665-BK gathers from teachers. The respondents are parents, teachers and other Education personnel.
Form SSA-5665 is currently available electronically to school administrators at http://www.socialsecurity.gov/schools1.htm. The DDS or SSA may send a request to a school’s central administration, which refers the request to a child’s teacher(s) who then accesses the SSA-5665-BK through the link. The teacher(s) forwards the completed form to the school’s central administration, which uploads the form and existing records to SSA’s Electronic Records Express (ERE) system. To reduce disability processing time, SSA developed ERE (OMB Control No. 0960-0753). ERE is an Internet-based system which allows anybody who must provide information about disability claimants to SSA to do so quickly and efficiently online. Because ERE has only recently been implemented, most SSA-5665s are still completed manually; however, we anticipate that more schools will register and use this system in the future. SSA intends to make Form SSA-5666 available electronically through ERE in the near future.
The information requested on these forms does not duplicate information requested in any other way. Similar information already available cannot replace the information recorded on the forms.
The collection of information does involve small business or other small entities (i.e., schools and school teachers); however, there will be no significant impact.
The information on Form SSA-5665-BK and SSA-5666 must be collected to comply with regulations cited in Item 1 above. The cost of the Title XVI disability program would increase if the forms were not used, because (1) non-uniform documentation of information about children’s functioning in school settings would be less efficient, less reliable, and less clear for purposes of quality assurance and any other reviews; and (2) under the pressure of high workloads, the DDSs would be more open to cutting corners in obtaining information from schools and education programs. The availability of nationally prepared and approved forms greatly facilitates this task. There are no technical or legal obstacles that prevent burden reduction.
There are no special circumstances that would cause this information collection to be conducted in a manner consistent with 5 CFR 1320.5.
SSA published the 60-day advance Federal Register Notice on March 26, 2008, at 73 FR 16087, and received no public comments. SSA published the second on May 28, 2008, at 73 FR 30656.
In preparing the initial versions of the SSA-5665-BK and SSA-5666, we considered comments/opinions from external stakeholders such as teachers and advocacy groups.
SSA provides no gifts to the respondents.
The information provided on the forms is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 422; 5 U.S.C. 552 (Freedom of Information Act); 5 U.S.C. 552a (Privacy Act of 1974); and OMB Circular, No. A-130.
The information recorded may be considered sensitive, in that it describes limitations imposed on a child’s daily functioning as a result of his/her impairment or combination of impairments. However, a disability determination cannot be made without obtaining a description of the child’s ability to function on a day-to-day basis.
On a yearly basis, the form SSA-5665-BK is used by approximately 618,000 teachers and school personnel, all of whom are in the Respondent Type category of State/Local/Tribal Government. Our estimate of the burden per response for form SSA-5665-BK is 20 minutes, for an annual hour burden of 206,000 hours.
On a yearly basis, the form SSA-5666 is used by approximately 615,000 school administrative personnel, all of whom are in the Respondent Type category of State/Local/Tribal Government. Our estimate of the burden per response for Form SSA-5666 is 15 minutes, for an annual hour burden of 153,750 hours.
The combined total annual burden for both forms is 359,750 as shown on the chart below:
Form Number |
Number of Respondents |
Frequency of Response |
Average Burden per Response (minutes) |
Total Annual Burden (hours) |
SSA-5665-BK |
618,000 |
1 |
20 |
206,000 |
SSA-5666 |
615,000 |
1 |
15 |
153,750 |
Totals |
1,233,000 |
|
|
359,750 |
As discussed in item 2, the DDS may occasionally ask others for similar kinds of information about a working-age child’s functioning in work-related activities. Our estimate is that this might happen in 3000 cases annually, with a 10-minute burden per response, resulting in an annual hour burden of 500 hours. We would expect the SSA-5665-BK to be used in such instances (though not the SSA-5666); the additional number of cases is included in the figures shown above for the SSA-5665-BK.
The total burden is reflected as burden hours. No separate cost burden has been calculated.
There is no known cost burden to the respondents.
The annual cost to the Federal Government is approximately $6,856,080. The annual cost to the Federal government for Form SSA-5665-BK is approximately $5,146,680.00; and the cost for Form SSA-5666, approximately $1,709,400.00. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.
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.
The results of the information collection will not be published.
OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). This exemption was granted so that otherwise usable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.
SSA is not requesting an exception to the certification requirements. Please note, however, that statistical survey methodology is not used for this information collection.
B. Collections of Information Employing Statistical Methods
Statistical methods are not used for this information collection.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Author | Bendann |
| Last Modified By | Davidson, Liz |
| File Modified | 2008-07-16 |
| File Created | 2008-07-16 |