Addendum to the Supporting Statement for 0960-0646

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Addendum to the Supporting Statement for

Teacher Questionnaire, Form SSA-5665-BK

Request for Administrative Information, Form SSA-5666

20 CFR 416.924(a)(2)

OMB No. 0960-0646

The Form SSA-5665-BK (Teacher Questionnaire) and Form SSA-5666 (Request for Administrative Information) are distinct but related forms used by SSA to obtain information from the education community. Separate forms are needed to avoid an unnecessary burden on teachers, and to improve the likelihood of obtaining the information we need to adjudicate claims for disability.

The information requested for the SSA-5665-BK must come from a child’s teacher. However, the information requested for the SSA-5666 cannot be provided by a child’s teacher without considerable extra effort on the teacher’s part, because administrative records are generally kept in a school’s (or school system’s) record-keeping office. Therefore, even though teacher information and administrative information will almost always be requested at the same time, the two forms may need to go to separate addresses in a school, and different individuals will usually respond to them.

We are requesting minor revisions to both forms.

SSA-5665-BK:

Cover Letter – we have changed the heading to read:

TEACHER QUESTIONNAIRE

ANSWERS FOR CLASSROOM OR HOME-SCHOOL TEACHERS

ABOUT THE QUESTIONNAIRE

This change reflects the need to include home-school teachers as a possible source of information about a child’s functioning and to recognize that person as the provider of such information.

SSA-5665-BK and SSA-5666 (per item 15 of the Supporting Statement):

Page 1 – We have changed the box in the upper left corner to read:

REQUESTING OFFICE NAME AND ADDRESS

This change responds to the request from the Office of Disability Review and Adjudication (ODAR) that we make these two forms available for use by their adjudicators in documenting childhood disability claims.