Teacher Questionnaire; Request for Administrative Information

Forms and Documents

Document	Type	Status	Availability
Form SSA-5665-BK SSA-5665-BK (paper)	Form and Instruction	Removed	Available
Form SSA-5666 SSA-5666 (Electronic)	Form and Instruction	Modified	Available
Form SSA-5665-BK (Elect SSA-5665-BK (Electronic)	Form and Instruction	Modified	Repair queued
Form SSA-5666 SSA-5666	Form and Instruction	Removed	Available
Supporting Statement - 0646.docx	Supporting Statement A	Uploaded 2017-07-03	Available
Addendum - 0646.docx	Supplementary Document	Uploaded 2017-07-03	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
9683	SSA-5665-BK (paper)	Form and Instruction	Removed
211838	SSA-5666 (Electronic)	Form and Instruction	Modified
197497	SSA-5665-BK (Electronic)	Form and Instruction	Modified
183366	SSA-5666	Form and Instruction	Removed

ICR Details

OMB Control No: 0960-0646	ICR Reference No: 201703-0960-017
Status: Active	Previous ICR Reference No: 201404-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Teacher Questionnaire; Request for Administrative Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/13/2017
	Date Received in OIRA: 07/03/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	36 Months From Approved	12/31/2017
Responses	404,564	0	510,093
Time Burden (Hours)	251,178	0	316,824
Cost Burden (Dollars)	0	0	0

---

Abstract: 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 1383b Name of Law: Social Security Act
   US Code: 42 USC 1382c Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 17494	04/11/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 27939	06/19/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
SSA-5666 (Electronic)	SSA-5666	Request for Administrative Information
SSA-5665-BK (Electronic)	SSA-5665-BK (Electronic)	Teacher Questionnaire
SSA-5665-BK (paper)	SSA-5665-BK	Teacher Questionnaire
SSA-5666	SSA-5666	Request for Administrative Information

---

ICR Summary of Burden

	Total Approved	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	404,564	510,093	0	-4,405	-101,124	0
Annual Time Burden (Hours)	251,178	316,824	0	-2,630	-63,016	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: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The decrease in burden hours stems from a decrease in the number of child applications. In addition, because respondents only use the electronic versions of Forms SSA-5665-BK and SSA-5666, we will no longer use the paper forms unless absolutely necessary.

---

Annual Cost to Federal Government:

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 07/03/2017

---