Supporting Statement--0646(revised)

Supporting Statement for

Teacher Questionnaire, Form SSA-5665-BK

Request for Administrative Information, Form SSA-5666

ODAR Cover Letter to Teacher Questionnaire, HA-85

ODAR Cover Letter to Request for Administrative Information, HA-86

OMB No. 0960-0646

A. Justification

1. Introduction/Authoring Laws and Regulations

Section 1614(a)(3)(C) of the Social Security Act (the Act), as amended by Public Law 104-19, requires the Social Security Administration (SSA) to 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 SSA 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 SSA to consider all relevant evidence in the case record when determining whether a child has a disability under Title XVI of the Act (initial, reconsideration, or continuing disability determination). This may include medical evidence, school records, and employment history.

20 CFR 416.924(a)(2) requires that, when determining the effects of the child’s impairment(s), SSA 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 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. We use forms SSA-5665 and SSa-5666 for this purpose.

2. Description of Collections

When determining the effects of a child’s impairment(s), SSA obtains information about the child’s functioning from teachers, parents, and others who have the opportunity to observe the child on a daily basis. SSA obtains results of formal testing, teacher reports, therapy progress notes, individualized education programs, and other records of a child’s educational aptitude and achievement using forms SSA-5665 and SSA-5666. The respondents are parents, teachers, and other education personnel.

Form SSA-5665 is available electronically to school administrators on SSA’s website. The State Disability Determination Services (DDSs) 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 system. Although the SSA-5665-BK is available for online completion, some teachers may print and manually complete the form, then fax or mail it to the requesting office. Form SSA-5666 is available on SSA’s website as a PDF.

3. Use of Information Technology to Collect the Information

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Internet version of form SSA-5665. Based on our data, we estimate approximately 97% of respondents under this OMB number use the electronic version.

SSA intends to make Form SSA-5666 available electronically through ERE in the near future.

4. Why We Cannot Use Duplicate Information

The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain the same information.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting It Less Frequently

If we did not use form SSA-5665-BK and SSA-5666, the cost of the title XVI disability program would increase 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. The DDS and ODAR each collect the information only once; so we cannot collect it less frequently.

There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on April 06, 2011, at 76 FR 19175, and we received no public comments. The 30-day FRN published on June 30, 2011 at 76 FR 38448. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects 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. SSA only share the information with those who need to see it (to process the application), and we store the information securely.

11. Justification for Sensitive Questions

One could consider the information recorded on the SSA-5665-BK and the SSA-5666 to be sensitive, in that it describes limitations imposed on a child’s daily functioning by his or her impairment or combination of impairments. However, we cannot make a disability determination without obtaining a description of the child’s ability to function on a day-to-day basis.

12. Estimates of Public Reporting Burden

Form No.	Number of respondents	Frequency of response	Average burden per response (minutes)	Total Annual burden (hours)
SSA-5665-BK (electronic)	388,581	1	40	259,054
SSA-5665-BK (paper)	11,419	1	40	7,613
SSA-5666	397,000	1	30	198,500
Totals	797,000	-	-	465,167

The total burden for this ICR is 465,167 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

The first Federal Register Notice shows incorrect burden information for the SSA-5665-BK. We have corrected for this in the second Notice, in #12 below and on ROCIS.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $167,720. The annual cost to the Federal government for Form SSA-5665-BK is approximately $144,000; and the cost for Form SSA-5666, approximately $23,720. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There has been a decrease in burden hours. This change stems from a decrease in the number of child applications from birth to age 18. There has been in increase in burden hours. This change also stems from an increase in the completion time from 20 minutes to 40 minutes for form SSA-5665-BK, and 15 minutes to 30 minutes for form SSA-5666.

16. Plans for Publication of Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper forms SSA-5665-BK and SSA-5666, we will not publish the OMB approval expiration date. OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so that SSA would not have to destroy stocks of otherwise usable forms with expired OMB approval dates, avoiding Government waste.

For the Internet version of forms SSA-5665-BK and SSA-5666, SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.