Addendum to Supporting Statement

ADDENDUM TO THE 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

Change to SSA-5665-BK: Cover letter to Teachers and Home School Teachers

Change 1: We are revising the language under section Q. WHY DO YOU NEED INFORMATION FROM ME?

• Old Language:

To decide whether a child qualifies for disability benefits, we use information from both medical and non-medical 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 eligibility may be related to his or her level of functioning at school, at home, or in the community. The information you provide about his or her day-to-day functioning in school will help us to determine the effects of the child’s impairment(s) on his or her functioning. 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 the child has been (or was) in your class 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.

• New Language:

To decide whether a child qualifies for disability benefits, we use information from both medical and non-medical 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.

Justification 1: We are revising change in accordance with the Commissioner’s writing requirements.

Change 2: We are revising the language under section Q. IS THIS REQUEST REDUNDANT?

• Old Language:

IS THIS REQUEST REDUNDANT? THIS CHILD HAS ALREADY BEEN EVALUATED UNDER THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA).

• New Language:

IS THIS REQUEST REDUNDANT? WE (OR OTHERS) HAVE ALREADY EVALUATED THIS CHILD UNDER THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA).

Justification 2: We are revising change in accordance with the Commissioner’s writing requirements.

Change 3: We are revising the language under section Q. I DO NOT THINK THE CHILD IS DISABLED. SHOULD I COMPLETE THIS FORM?

Old Language:

• Yes. Under Social Security law, we are responsible for deciding whether this child is disabled, and we will be making 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.

New Language:

• 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.

Justification 3: We are revising change in accordance with the Commissioner’s writing requirements.

Change 4: We are revising the language under section Q. THIS FORM IS LONG. DO I NEED TO ANSWER EVERY QUESTION?

• Old Language:

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. It is also organized 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 skip to the next section.

• New Language:

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 l imitations in that domain. When you have not observed any limitations in a domain, you may check that block and move to the next section.

Justification 4: We are revising change in accordance with the Commissioner’s writing requirements.

Change 5: We are adding ODAR cover letters to form SSA-5665-BK and SSA-5666

Justification 5: The letters will explain ODAR’s reason for requesting teachers and administrative offices to complete the respective forms and provide copies of a child’s records. The Social Security Administration (SSA) will produce the letters on SSA’s letterhead, with ODAR’s identifying information in the upper right corner. Each letter will enclose the respective form and a completed SSA-827, Authorization To Disclose Information to the Social Security Administration.

Change 6: We are increasing the time estimate for SSA-5665-BK to 40 minutes, and the time estimate for the SSA-5666 to 30 minutes, as indicated in the Paperwork Reduction Act statements on both forms.

Justification 6: Since the last OMB clearance of these two forms in 2008, we have received three public comments concerning the current time estimates given for the forms. The commenter made recommendations that we increase the time estimate for both forms. We agree with their recommendation, and we are doubling the time estimate for each form.

The SSA-5665-BK, Teacher Questionnaire, requires only the completion of the form, for which we believe a 40-minute time estimate is adequate.

The SSA-5666, Request for Administrative Information, requires completion of the form (which is only one-page) and the copying of documents from the child’s existing school records. We believe a 30-minute time estimate for these tasks is adequate.

We believe these are reasonable and appropriate changes; however, we will consider any additional comments in the future that reflect ongoing concern about this issue, and we will take appropriate action.

Minor Revisions to the Collection Instrument for SSA-5665-BK and SSA-5666

We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the first page of the form.