Teacher Questionnaire; Request for Administrative Information

Forms and Documents

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Collection	Type	Status	Form
9683	SSA-5665-BK (paper)		Unchanged
197497	SSA-5665-BK (electronic)		Unchanged
183366	SSA-5666		Modified

ICR Details

OMB Control No: 0960-0646	ICR Reference No: 201304-0960-006
Status: Historical Inactive	Previous ICR Reference No: 201103-0960-016
Agency/Subagency: SSA	Agency Tracking No:
Title: Teacher Questionnaire; Request for Administrative Information
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Preapproved	Conclusion Date: 08/23/2013
	Date Received in OIRA: 08/06/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	09/30/2014	10/31/2014
Responses	797,000	0	797,000
Time Burden (Hours)	465,167	0	465,167
Cost Burden (Dollars)	0	0	0

---

Abstract: Non-substantive change to the collection instrument Form SSA-5666; revising words mental retardation to intellectual disability; no change in burden data. When determining the effects of a 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. 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 on the SSA-5665 and SSA-5666. The respondents are parents, teachers, and other Education personnel.

---

Authorizing Statute(s): US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 1383b Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Final or interim final rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 19175	04/06/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 38448	06/30/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
SSA-5665-BK (paper)	SSA-5665-BK
SSA-5666	SSA-5666
SSA-5665-BK (electronic)	SSA-5665-BK (Electronic)

---

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	797,000	797,000	0	0	0	0
Annual Time Burden (Hours)	465,167	465,167	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $167,720

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/06/2013

---