Form SSA-5665-BK (Elect SSA-5665-BK (Elect Teacher Questionnaire

TEACHER QUESTIONNAIRE
ANSWERS FOR TEACHERS OR HOME-SCHOOL TEACHERS
ABOUT THE QUESTIONNAIRE
One of your current or former students has filed a claim for disability benefits. We need information from you
to help us make our decision. Please complete the enclosed questionnaire.
Q. WHY DO YOU NEED INFORMATION FROM ME?
A. To decide whether a child qualifies for disability benefits, we use information from both medical and nonmedical sources. Medical sources include doctors and other health care professionals; non-medical sources
include teachers and other people who spend time with the child. Information from sources who know the child
well is important, because a child’s level of functioning at school, at home, or in the community may affect his
or her eligibility. The information you provide about the child’s day-to-day functioning in school will help us
to determine the effects of the child’s impairment(s). It will also help us to compare this child’s functioning to
that of other children the same age who do not have impairments. We need this information from you even if
you have taught (or did teach) the child for only a short time. Your information is not the only information we
will be considering when we decide if the child qualifies for disability benefits, but it is very important to us.
Q. IS THIS REQUEST REDUNDANT? WE (OR OTHERS) HAVE ALREADY EVALUATED THIS
CHILD UNDER THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA).
A. The definition of disability in the Social Security Act is entirely separate from the definition of an
“educational disability” in the IDEA. We must determine whether a child’s impairment(s) meets the SSA
definition of disability, regardless of the child’s standing under the IDEA definition of educational disability.
Q. I DO NOT THINK THE CHILD IS DISABLED. SHOULD I COMPLETE THIS FORM?
A. Yes. Under Social Security law, we are responsible for deciding whether this child is disabled, and we will
make our decision based on all of the medical, school, and other information we receive. Your observations
will help us to have a more complete picture of the child’s daily functioning and to make a fair and accurate
decision. Your completion of this form does not constitute an endorsement of our decision.
Q. THIS FORM IS LONG. DO I NEED TO ANSWER EVERY QUESTION?
A. Not always. The form uses check boxes and multiple--choice questions to help you provide specific
information as easily and quickly as possible, so it is not as long as it may appear. We also organized it into
sections that cover broad domains of functioning. For each section, there is an option to check one block
indicating that you have not observed any limitations in that domain. When you have not observed any
limitations in a domain, you may check that block and move to the next section.
We appreciate your cooperation, your time, and your effort in completing the questionnaire.

Form SSA-5665-BK (01-2006) ef (01-2006)

See Revised Privacy Act
Statement

See Revised Paperwork
Reduction Act Statement

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Teacher Questionnaire
Collection and Use of Personal Information
Sections 1614 and 1633 of the Social Security Act, as amended, and 20 CFR 416.924a(a),
authorize us to collect this information. We will use the information you provide to make
a decision on the named claimant’s claim.
The information you furnish on this form is voluntary. However, failure to provide the
requested information could prevent us from making an accurate and timely decision on
the named claimant’s claim.
We rarely use the information you supply for any other purpose than to make a decision
on a claimant’s disability. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate audit or investigative activities necessary to assure the integrity
of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally-funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Systems of Records Notice 60-0089 (Claims Folder
Systems). The Notice, additional information about this form, and any other information
regarding our systems and programs, are available on-line at www.socialsecurity.gov or
at your local Social Security office.

SSA will insert the following revised PRA Statement into the form at its next
scheduled reprinting:
Paperwork Reduction Act Statement – This information collection meets the requirements of 44
U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need
to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 40 minutes to read the instructions, gather the facts, and
answer the questions. If you have questions about how to complete the form, contact the Requesting
Office; see page 1, upper left corner, for the name, address, and phone number of the Requesting
Office. If you need the address or phone number for the Requesting Office, you can get it by calling
Social Security at 1-800-772-1213 (TTY 1-800-325-0778). SEND THE COMPLETED FORM TO
THE REQUESTING OFFICE. You may send comments on our time estimate above to: SSA, 6401
Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
this address, not the completed form.