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-5665-BK (Elect Teacher Questionnaire	Form and Instruction	Modified	Available
Supporting Statement - 0646 (Final).docx	Supporting Statement A	Uploaded 2026-07-31	Available
Addendum - 0646 (Final).docx	Supplementary Document	Uploaded 2026-07-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
211838	SSA-5666 (Administrators)	Other-Cover Letter	Modified
211838	SSA-5666 (Administrators)	Form and Instruction	Modified	Request for Administrative Information
197497	SSA-5665-BK (Teachers)	Other-Cover Letter	Modified
197497	SSA-5665-BK (Teachers)	Form and Instruction	Modified	Teacher Questionnaire

ICR Details

OMB Control No: 0960-0646	ICR Reference No: 202607-0960-002
Status: Received in OIRA	Previous ICR Reference No: 202008-0960-016
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	Date Submitted to OIRA: 07/31/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2026
Responses	366,210	337,725
Time Burden (Hours)	362,777	209,952
Cost Burden (Dollars)	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 observe the child on a daily basis. SSA requests teachers complete the SSA-5665, Teacher’s Questionnaire to obtain a report on the child’s daily overall functioning, comprehension, and known medical conditions throughout the school day. SSA requests the school administration to complete the SSA-5666, Request for Administrative Information, to obtain formal testing results, other teacher reports, therapy progress notes, individualized education program documents, and other records of a child's educational aptitude and achievements. The respondents are teachers, educational administrators, 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:
	91 FR 30774	05/26/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 48475	07/31/2026
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 (Teachers)	SSA-5665-BK (Electronic)	Teacher Questionnaire
SSA-5666 (Administrators)	SSA-5666	Request for Administrative Information

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ICR Summary of Burden

table that charts list 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	366,210	337,725	0	0	28,485	0
Annual Time Burden (Hours)	362,777	209,952	0	0	152,825	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 cleared the this ICR in 2023, the burden was 209,952 hours. However, we are currently reporting a burden of 218,353 hours. This change stems an increase in the number of responses from 337,725 to 366,210. 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. *Note: The total burden reflected in ROCIS is 362,777, while the burden cited in #12 of the Supporting Statement is 218,353. This discrepancy is because the ROCIS burden also reflects the learning cost burden. In contrast, the chart in #12 above reflects actual burden.

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Annual Cost to Federal Government: $5,564,769

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: 07/31/2026

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