SSA-5665-BK (Elect Teacher Questionnaire

Form SSA-5665-BK (06-2018) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 10
OMB No. 0960-0646

Teacher Questionnaire
Answers For Teachers or Homeschool 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 a decision. Please complete the enclose 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
non-medical sources. Medical sources include doctors and other health care professionals; nonmedical 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 dayto-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 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.
Q. The 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
the form 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 on to the next section.

We appreciate your cooperation, your time, and your effort in completing the questionnaire.

Form SSA-5665-BK (06-2018) UF

Page 2 of 10

Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 223 and 1631(e) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent us from making an accurate and timely decision on the named claimant’s eligibility for benefits.
We will use the information to make a determination of eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To specified business and other community members and Federal, State, and local agencies for
verification of eligibility for benefits under section 1631(e) of the Act; and
2. To Federal, State, or local agencies for administering cash or non-cash income maintenance or
health maintenance programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a person’s
eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089,
entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are available on
our website at www.socialsecurity.gov/foia/bluebook.
See Revised Privacy Act &

PRA Statements attached
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 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 3, 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.

PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM

Form SSA-5665-BK (06-2018) UF
Discontinue Prior Editions
Social Security Administration

Page 3 of 10
OMB No. 0960-0646

Requesting Office Name and Address

Attach Label or Type in Claimant Name

Teacher Questionnaire
This Form Should Be Completed By The Person(s) Most
Familiar With The Child's Overall Functioning.
Name of School:
1. How long have you known, or did you know, this child?

2. How often, and for how long, do you, or did you, see this child?

For what subjects:

3. Actual Grade Level:

Current Instructional Levels

Special Ed. Services & Frequency

Reading Level:
Student/Teacher Ratio:

Math Level:
Written Language
Level:

4. Is there, or was there, an unusual degree of absenteeism?

5. Dominant Language:

English

Spanish

Yes

No

If yes, please explain:

Other (please specify)

6. Any other names by which the child is known:

IMPORTANT
Please compare this child's functioning to that of same-aged
children who do not have impairments
If the child is receiving special education services, please be sure to compare his
or her functioning to that of same-aged, unimpaired children who are in regular education.

Form SSA-5665-BK (06-2018) UF

Page 4 of 10

1. Acquiring and Using Information
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section 2.
YES, the child has problems functioning in this domain.
Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has:
1
No Problem

2
A slight problem

3
An obvious problem

4
A serious problem

5
A very serious problem
Rating

1. Comprehending oral instructions
2. Understanding school and content vocabulary
3. Reading and comprehending written material
4. Comprehending and doing math problems
5. Understanding and participating in class discussions
6. Providing organized oral explanations and adequate descriptions
7. Expressing ideas in written form
8. Learning new material
9. Recalling and applying previously learned material
10. Applying problem-solving skills in class discussions

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

What else can you tell us about the child's problems with these activities? For example, how independent is
the child in doing them? Does the child get extra help, or an unusual degree of structure or support? If so,
what kind and how often? (Continue on the last page if needed.)

Form SSA-5665-BK (06-2018) UF

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2. Attending and Completing Tasks
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section 3.
YES, the child has problems functioning in this domain.
Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has
1
No Problem

2
A slight problem

3
An obvious problem

4
A serious problem

5
A very serious problem

attention when
1. Paying
spoken to directly

1

2

3

4

5

Frequency of Problem
Daily
Monthly Weekly
Hourly

attention during
2. Sustaining
play/sports activities

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

long enough to
3. Focusing
finish assigned activity or task

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

to task
4. Refocusing
when necessary

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

out
5. Carrying
single-step instructions

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

out
6. Carrying
multi-step instructions

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

from on activity to
8. Changing
another without being disruptive

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

own things
9. Organizing
or school materials

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

class/
10. Completing
homework assignments

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

work accurately
11. Completing
without careless mistakes

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

without distracting
12. Working
self or others

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

at reasonable pace/
13. Working
finishing on time

1

2

3

4

5

Monthly

Weekly

Daily

Hourly

Rating

7. Waiting to take turns

What else can you tell us about the child's problems with these activities? For example, how independent is
the child in doing them? Does the child get extra help, or an unusual degree of structure or support? If so,
what kind and how often? (Continue on the last page if needed.)

Form SSA-5665-BK (06-2018) UF

Page 6 of 10

3. Interacting and Relating with Others
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section 4.
YES, the child has problems functioning in this domain. Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has
1
2
3
4
5
No Problem
A slight problem
An obvious problem A serious problem A very serious problem
Frequency of Problem
Rating
Monthly Weekly Daily Hourly
cooperatively
1
2
3
4
5
1. Playing
with other children
1

2

3

4

5

Monthly Weekly Daily Hourly

1

2

3

4

5

Monthly Weekly Daily Hourly

1

2

3

4

5

Monthly Weekly Daily Hourly

permission
5. Asking
appropriately

1

2

3

4

5

Monthly Weekly Daily Hourly

rules
6. Following
(classroom, games, sports)

1

2

3

4

5

Monthly Weekly Daily Hourly

adults
7. Respecting/obeying
in authority

1

2

3

4

5

Monthly Weekly Daily Hourly

experiences
8. Relating
and telling stories

1

2

3

4

5

Monthly Weekly Daily Hourly

language appropriate
9. Using
to the situation and listener

1

2

3

4

5

Monthly Weekly Daily Hourly

and maintaining relevant
10. Introducing
and appropriate topics of conversation

1

2

3

4

5

Monthly Weekly Daily Hourly

1

2

3

4

5

Monthly Weekly Daily Hourly

1

2

3

4

5

Monthly Weekly Daily Hourly

1

2

3

4

5

Monthly Weekly Daily Hourly

2. Making and keeping friends
3. Seeking attention appropriately
4. Expressing anger appropriately

11. Taking turns in conversation
meaning of facial expression,
12. Interpreting
body language, hints, sarcasm
Using adequate vocabulary and grammar
13. to express thoughts/ideas in general,
everyday conversation

Has it been necessary to implement behavior modification strategies for the child?

Yes

No

If yes, please explain below (e.g., behavior plan, personal assistant, time-out, quiet room, removal from the
classroom, change of school placement, suspension, expulsion). Please be as detailed as possible.

Interacting and Relating with Others continued on next page

Form SSA-5665-BK (06-2018) UF

Page 7 of 10

3. Interacting and Relating with Others (Continued)
What else can you tell us about the child's problems with these activities? For example, how independent is
the child in doing them? Does the child get extra help, or an unusual degree of structure or support? If so,
what kind and how often? (Continue on the last page if needed.)

How much of the child's speech can you, as a familiar listener,
understand on the first attempt?

Very
Little

No more
than 1/2

1/2 to
2/3

Almost
All

1. When the topic of conversation is known
2. When the topic of conversation is unknown
How much of the child's speech can you, as a familiar listener,
understand after repetition and/or rephrasing?

4. Moving About and Manipulating Objects
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section 5.
YES, the child has problems functioning in this domain. Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has
1
2
3
4
5
No Problem
A slight problem
An obvious problem A serious problem A very serious problem
Rating
body from one place to another (e.g., standing, balancing, shifting
1. Moving
weight, bending, kneeling, crouching, walking, running, jumping, climbing

1

2

3

4

5

and manipulating things (e.g., pushing, pulling, lifting, carrying,
2. Moving
transferring objects; coordinating eyes and hands to manipulate small objects

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

3. Demonstrating strength, coordination, dexterity in activities or tasks
4. Managing pace of physical activities or tasks
5. Showing a sense of body's location and movement in space
6. Integrating sensory input with motor output
7. Planning, remembering, executing controlled motor movements

What else can you tell us about the child's problems with these activities? For example, how independent is
the child in doing them? Does the child get extra help, or an unusual degree of structure or support? If so,
what kind and how often? (Continue on the last page if needed.)

Form SSA-5665-BK (06-2018) UF

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5. Caring for Himself or Herself
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section 6.
YES, the child has problems functioning in this domain. Please mark a rating for each activity listed below.
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has
1
2
3
4
5
No Problem
A slight problem
An obvious problem A serious problem A very serious problem

1. Handling frustration appropriately

1

2

3

4

5

Frequency of Problem
Monthly Weekly Daily Hourly

2. Being patient when necessary

1

2

3

4

5

Monthly Weekly Daily Hourly

3. Taking care of personal hygiene

1

2

3

4

5

Monthly Weekly Daily Hourly

for physical needs
4. Caring
(e.g., dressing, eating)

1

2

3

4

5

Monthly Weekly Daily Hourly

in, or being responsible for,
5. Cooperating
taking needed medications

1

2

3

4

5

Monthly Weekly Daily Hourly

good judgment regarding personal
6. Using
safety and dangerous circumstances

1

2

3

4

5

Monthly Weekly Daily Hourly

and appropriately asserting
7. Identifying
emotional needs

1

2

3

4

5

Monthly Weekly Daily Hourly

appropriately to changes in
8. Responding
own mood (e.g., calming self)

1

2

3

4

5

Monthly Weekly Daily Hourly

appropriate coping skills to meet
9. Using
daily demands of school environment

1

2

3

4

5

Monthly Weekly Daily Hourly

10. Knowing when to ask for help

1

2

3

4

5

Monthly Weekly Daily Hourly

Rating

What else can you tell us about the child's problems with these activities? For example, how independent is
the child in doing them? Does the child get extra help, or an unusual degree of structure or support? If so,
what kind and how often? (Continue on the last page if needed.)

Form SSA-5665-BK (06-2018) UF

Page 9 of 10

6. Medical Conditions and Medications/Health and Physical Well-Being
1. Describe below any chronic or episodic condition (e.g., asthma, sickle cell anemia, depression,
seizures). Does the condition have any physical effects (e.g., shortness of breath, reduced stamina,
psychomotor retardation, incontinence, pain) that interfere with the child's functioning at school? How
often does the child experience these physical effects related to the condition?

2. Please check any of the following that the child uses:
Glasses

Nebulizer/Inhaler

Assistive Technology device

Hearing Aid

Auditory Trainer

Orthopedic devices

Prosthesis

Other (please specify)
No

Don't Know

4. Does this child take the medication on a regular basis?

Yes

No

Don't Know

5. Does this child's functioning change after taking medication?

Yes

No

Don't Know

Yes

No

3. Is medication prescribed for this child?

Yes

Specify below, if known.

If yes, please explain below

6. Does this child frequently miss school due to illness?
If yes, please explain below

What else can you tell us about the physical effects of the child's physical or mental condition or treatment
for the condition? (Continue on the last page if needed.)

Please Provide Your Name and Title on Next Page. Add Any Remarks as Needed.

Form SSA-5665-BK (06-2018) UF

Page 10 of 10

7. Additional Comments
Use this section for continuation of any previous sections. You may also use this section to make any
additional remarks, or to note any changes in the child's functioning, for better or worse, that you would like
to address.

This form completed by:
Name/Title

Date

If we need more information about this child,
• Is there a phone number where we can reach you? (
• Is there a best time to call you?

a.m.

)
p.m.

Name/Title

Date

If we need more information about this child,
• Is there a phone number where we can reach you? (
• Is there a best time to call you?

a.m.
Thank You

)
p.m.