SSA-5666 - Request for Administrative Information

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FORM SSA-5666 (08-2023) UF
Discontinue Prior Editions
Social Security Administration
REQUESTING OFFICE NAME AND ADDRESS

Page 1 of 2
OMB No. 0960-0646
ATTACH LABEL OR TYPE IN CLAIMANT NAME

REQUEST FOR ADMINISTRATIVE INFORMATION
Please ask the person(s) most familiar with the child's records to complete this form.
Continue any answers as needed on next page.
Name of School
1. Has there been any recent evaluation or testing of this child? If yes, kind(s) of test/evaluation:

Date(s):

Please send us copies of all comprehensive evaluations, triennial assessments, psychological or speech/language testing,
current Individualized Education Programs, teacher/therapist progress reports, and all other records that can help us evaluate
the child's functioning.
2. Has the child been referred for assessment team evaluation or special class placement or
Date(s):
services? If yes, to whom?

3. Current Instructional Levels

Standardized Assessment Instrument

Score/Percentile Rank

Date(s):

Reading Level:
Math Level:
Written
Language Level:
4. Grade(s) repeated, if any:
K

1

2

3

4

5

6

7

8

9

10

11

12

5. Educational Disabilities, if any:
Intellectual Disability
Hearing Impairment/Deafness
Speech or Language Impairment
Visual Impairment/Blindness
Emotional Disturbance/Behavior Disorder
Orthopedic Impairment
Autism
Traumatic Brain Injury
6. Placement and Related Services (Check all that apply):
Regular Education, no special instruction
Hours/week:
Special Ed. Instruction
Inclusion - Sp. instr. in regular class
Resource Room
Self-contained, regular school
Self-contained, special school
Special school, non-public
Residential

Other Health Impairment (please specify)
Specific Learning Disability (please specify)
Developmental Delay (please specify)
Multiple Disabilities (please specify)

Therapies, etc:
Occupational Therapy
Physical Therapy
Speech - Language Therapy
Counseling (please specify)
Other (please specify)

PLEASE PROVIDE YOUR NAME AND TITLE ON THE NEXT PAGE

Hours/week:

Form SSA-5666 (08-2023) UF
Page 2 of 2
ADDITIONAL COMMENTS Use this section for continuation of any answers from page 1, and for any additional
information about this child's records that may help us obtain the information we need to evaluate the
child's functioning.

Name/Title

Date

Phone

Name/Title (If more than one person helped complete this form)

Date

Phone

THANK YOU
Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy Act
Statement
Attached
Sections 202, 221, 223, 1614(a), 1631(e), and 1633 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 an accurate and
timely decision on the named claimant’s eligibility for benefits claim filed.
We will use the information you provide to make a determination of eligibility for benefits. We may also share the information for
the following purposes, called routine uses:
• 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 Social Security Act; and
• To Federal, State, or local agencies (or agents on their behalf), for administering income or health maintenance
programs including programs under the Social Security Act.
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 Notices (SORN) 60-0089, Claims Folders
System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422; and 60-0320, Electronic Disability
(eDIB) Claim File, as published in the FR on June 4, 2020, at 85 FR 34477. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.
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 about 30 minutes to read the instructions, answer the
questions, and collect school records. If you have questions about how to complete the form, contact the Requesting Office; see
page 1, upper left corner for the name, address, and phone number of the Requesting Office. If you need the address or phone
number of 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.