Teacher Questionnaire; Request for Administrative Information

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-5666 Request for Administrative Information	Form and Instruction	Modified	Available
Form SSA-5666 SSA-5666 (Electronic)	Form and Instruction	Modified	Repair queued
Form SSA-5665-BK (Elect Teacher Questionnaire	Form and Instruction	Modified	Available
Supporting Statement - 0646 (Clean Copy).docx	Supporting Statement A	Uploaded 2022-05-16	Available
Supporting Statement - 0646.docx	Supporting Statement A	Uploaded 2020-12-09	Repair queued
Addendum - 0646 (Revised).docx	Supplementary Document	Uploaded 2022-05-16	Available
Addendum - 0646.docx	Supplementary Document	Uploaded 2020-12-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
211838	SSA-5666 (Electronic)	Form and Instruction	Modified	Request for Administrative Information
211838	SSA-5666 (Electronic)	Form and Instruction	Modified
211838	SSA-5666 (Electronic)	Other-Revised PA & PRA Statements	Modified
197497	SSA-5665-BK (Electronic)	Form and Instruction	Modified	Teacher Questionnaire
197497	SSA-5665-BK (Electronic)	Other-Revised PA & PRA Statements	Modified

ICR Details

OMB Control No: 0960-0646	ICR Reference No: 202008-0960-016
Status: Active	Previous ICR Reference No: 201703-0960-017
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 with change	Conclusion Date: 07/20/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/09/2020
Terms of Clearance: The agency made minor modifications to the supporting statement to clarify the description of the information collection and how it is submitted. The agency made a minor modification to the form to clarify when a respondent should leave a response blank.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2026	36 Months From Approved	07/31/2023
Responses	337,725	0	404,564
Time Burden (Hours)	209,952	0	251,178
Cost Burden (Dollars)	0	0	0

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Abstract: 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 uses Forms SSA-5665-BK and SSA-5666 to make one-time requests for teacher reports; results of formal testing; therapy progress notes; individualized education programs; and other records of a child’s educational aptitude and achievement. Forms SSA-5665-BK and SSA-5666 are available electronically to school and training program administrators on SSA’s website. State Disability Determination Services (DDS) or SSA may send a request for completion of the SSA-5665-BK to a child’s local school administrative office or training program, which refers the request to the child’s teacher(s), who then accesses the form through the link. The teacher(s) forwards the completed SSA-5665-BK to the school’s or training program’s administrative office, which uploads it to SSA’s Electronic Records Express (ERE) system. The DDS or SSA may send a request for completion of the SSA 5666 and copies of the child’s school records to the central or local administrative school office, depending on which office maintains the child’s individual academic records. The administrative office or training program can also upload the child’s records via ERE. Although the SSA-5665-BK and SSA 5666 are available for online completion, some teachers and school personnel may print and manually complete the forms, then fax or mail them to the requesting DDS or SSA office. Respondents are teachers and other education personnel.

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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

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 63630	10/08/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 79064	12/08/2020
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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ICR Summary of Burden

table that charts list 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	337,725	404,564	0	0	-66,839	0
Annual Time Burden (Hours)	209,952	251,178	0	0	-41,226	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: When we last cleared this IC in 2017, the burden was 251,178 hours. However, we are currently reporting a burden of 209,952 hours. This change stems from a decrease in the number of responses from 404,564 to 337,725. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.

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Annual Cost to Federal Government: $4,199,840

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? No

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Common Form ICR:  No

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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: 12/09/2020

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