Title of Information Collection and Form Number(s)

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                                                          Supporting Statement for 
Teacher Questionnaire, Form SSA-5665-BK
Request for Administrative Information, Form SSA-5666
20 CFR 404.1513, 416.913, and 416.924a(a)
OMB No. 0960-0646

A. 	Justification

    1. Introduction/Authoring Laws and Regulations
Sections 223(d)(5) and 1631(e) of the Social Security Act (Act) and 20 CFR 416.912(a) and 404.1512(a) of the Code of Federal Regulations authorize the Social Security Administration (SSA) to collect information found on Forms SSA-5665-BK and SSA‑5666. 

Sections 202 and 223(a) and (d) of the Act require SSA to apply a statutory definition of disability for minor children (individuals between the age of 15.5 to 18 years) in Title II child-in-care claims, and for adult children (under age 22 years) claiming Title II Childhood Disability Benefits.  Section 1614(a)(3)(C) of the Act, as amended by      Public Law 104-19, requires SSA to apply a statutory definition of disability for children (individuals under the age of 18 years) applying for Title XVI Supplemental Security Income (SSI) payments based on disability.  Sections 221 and 1633 of the Act allow the Commissioner of SSA to make appropriate or necessary administrative and other arrangements to carry out the functions of the agency under Titles II and XVI, respectively.     

20 CFR 404.1513 and 416.924a(a) of the Code of Federal Regulations require SSA to consider all relevant evidence in the case record when determining whether a child has a disability under Title II or XVI of the Act (initial, reconsideration, or continuing disability determination).  This may include medical evidence, school records, and employment history.  20 CFR 416.924a(a)(2) requires that when determining the effects of the child’s impairment(s), SSA obtains information about the child’s functioning from teachers, caregivers, parents, and others who have the opportunity to observe the child on a       day-to-day basis.  Education programs are an important source of evidence and often provide formal assessment results and other information from a variety of disciplines.  Evidence from educational programs varies a great deal in format, content, reliability, and usefulness.  The need exists, therefore, for an information collection instrument that ensures a degree of uniformity and consistency in the quantity and quality of information SSA receives about children’s impairment-related limitations.  We use Forms            SSA-5665-BK and SSA‑5666 for this purpose.

    2. Description of Collection
When determining how a child’s impairment(s) affects their eligibility for childhood Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) disability payments, or during a continuing disability review (CDR), SSA obtains information about the child’s functioning from teachers, parents, caregivers, and others who observe the child daily.  The Disability Determination Services (DDS) or the Social Security Administration (SSA) requests completion of the SSA-5665-BK and SSA-5666 during the initial application process, as well as when notified of new, updated, or changed education information during redetermination and appeals.

    • SSA-5665-BK, Teacher Questionnaire:  SSA uses this form to obtain a report from teachers on the child’s daily overall functioning, comprehension, and known medical conditions throughout the school day.

    • SSA-5666, Request for Administrative Information:  SSA uses this form 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 from the school administration. 

When DDS or SSA staff request completion of Forms SSA-5665-BK and SSA-5666 from a school or administrative office, they include a corresponding, customized cover letter with information and guidance outlined in the Disability Case Development Information Collections (OMB No. 0960-0555).  School and training program administrators can access Forms SSA-5665-BK and SSA-5666 electronically on SSA’s website.  DDS or SSA staff can request completion of the forms, along with copies of other school records, in various ways, including mailing the request; however, they often send requests electronically via SSA’s Electronic Records Express (ERE, OMB No. 0960-0753) or other electronic means such as secure email partner agreements.  ERE is a web application that allows users to submit and store medical records and other evidence electronically.  Individual school systems maintain partnerships and agreements with SSA and DDSs to receive, upload, download, and share information electronically through ERE.  DDS or SSA staff may send a request for completion of the forms 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.  SSA or DDS staff rarely request or receive these forms via mail; when this occurs, staff electronically fax or scan the documents into the child’s electronic folder for adjudication.

We identified the following psychological costs based on the requirements for this information collection:

Psychological Cost:
    • Requirement for Program:  Forms SSA-5665-BK and SSA-5666 require respondents to provide personal information about the child’s functioning, capabilities, and limitations to determine how the child’s impairment(s) affect their eligibility for childhood SSI or SSDI payments.
    • Psychological Cost:  Respondents may perceive the request to fill out the forms as time-consuming and stressful, and they may view the information requested as invasive, which can lead them to delay or abandon completing the forms.

We understand these psychological costs may cause respondents to delay their completion of the information collection or cause them to abandon the information collection entirely.  However, we require full completion of this collection for the child applicant or recipient to receive disability payments.  Therefore, we have taken this potential psychological cost into account when calculating our burden in #12 below.

The respondents are teachers, special educators, and other educational personnel who are familiar with the child, and educational personal or administrative staff that are able to provide DDS or SSA with the relative information regarding school records.

    3. Use of Information Technology to Collect the Information
SSA provides fillable and printable PDF versions of Forms SSA-5665-BK and SSA-5666 on SSA’s website.  Respondents may download the fillable versions, complete them, and submit them through SSA’s Electronic Records Express (ERE) System (OMB No.	 0960-0753).  Based on our data, 100% of respondents complete the fillable PDF forms and submit them electronically through ERE.  This information collection does not currently allow for full electronic completion under the Government Paperwork Elimination Act as it has been conveyed to SSA by OIRA, as we do not have a fully electronic version, which allows respondents to both complete and submit these forms through an Internet‑based application.  We are working with the team developing the agency’s mobile-accessible, online processes for completing and uploading forms and they expect to have functionality available to support several more forms in the next      3-6 years.  Therefore, we intend to make this available online for electronic submission in 3‑6 years, as soon as possible considering supporting functionality, prioritization, and resources.  Once the electronic submission version of the form is ready for implementation, we will submit a Change Request to OMB for prior approval.

    4. Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it precludes duplication.  SSA does not use another collection instrument to obtain similar data.  

    5. Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities. 

    6. Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Forms SSA-5665-BK and SSA-5666, the cost of the Title XVI and  Title II disability programs would increase because non-uniform documentation of information about a child’s functioning in a school setting or training program would make quality assurance and other reviews less efficient, less reliable, and less clear.  Since we collect the information only once, we cannot collect it less frequently.  There are no technical or legal obstacles to burden reduction.

    7. Special Circumstances 
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

    8. Solicitation of Public Comment and Other Consultations with the Public 
The 60-day advance Federal Register Notice published on May 26, 2026, at 91 FR 30774, and we received no public comments.  The 30-day FRN published on July 31, 2026, at 91 FR 48475.  If we receive any comments in response to this Notice, we will forward them to OMB.  We did not consult with the public in the development revision of this form.

    9. Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents. 

    10. Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

    11. Justification for Sensitive Questions
The collection contains information that may disclose sensitive material because it describes limitations imposed on a child’s daily functioning or impairment(s). However, SSA cannot make a disability determination without obtaining a description of the child’s ability to function on a day-to-day basis; therefore, we require the information from this collection to ensure we obtain a complete medical and non-medical record to fulfill the disability adjudicative process.

    12. Estimates of Public Reporting Burden
Please see the burden chart below:
	
Method
of Completion
Number 
of Respondents
Frequency
of 
Response
Average Burden Per Response (minutes)
Estimated Total Annual Burden (hours) 
Average Theoretical Cost Amount (dollars)*
Total Annual Opportunity Cost (dollars) **
SSA-5665-BK (Teachers)

211,487
1
40
140,991
$33.85*
$4,772,557**
SSA-5666 (Administrators)

154,723
1
30
77,362
$55.82*
$4,318,347**
Totals
366,210


218,353

$9,090,904**
* We based this figure on Teachers and Instructors worker’s hourly wages, as well as on the average Education Administrator’s Hourly wages as reported by Bureau of Labor Statistics data (Occupational Employment and Wage Statistics).
** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents will spend to complete the application.  There is no actual charge to respondents to complete the application.

We did not include travel time as per our current management information data, respondents who complete the paper forms return them to us via submittable PDF through ERE (OMB No. 0960-0753) only.

We calculated the following Learning Cost time burden based on the estimated time and effort we expect respondents will take to learn about this program, its applicability to their circumstances, and to cover any additional research we believe respondents may need to take to understand how to comply with the program requirements (beyond reading the instructions on the collection instrument):

Modality of Completion
Total Number of Respondents 
Frequency of Response
Estimate Learning Cost (minutes)
Estimated Total Annual Burden (hours)
Total Annual Learning Cost (dollars)***
SSA-5665-BK
(Teachers)
211,487
1
30
105,744
$3,579,434***
SSA-5666
(Administrators)

154,723
1
15
38,681
$2,159,173***
Totals
366,210


144,425
$5,738,607***
***We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.

NOTE:  We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.

We base our burden estimates on current management information data, which includes data from interviews, reports, as well as from years of conducting this information collection.  Per our management information data, we believe that 45 minutes          (SSA-5665-BK-30 minutes, and SSA-5666-15 minutes) accurately shows the average burden per response for learning about the program; receiving notices; reading and understanding instructions; gathering the data and documents needed; answering the questions and completing the information collection instrument; scheduling appointments or phone calls or consulting with any third parties, if necessary; and waiting to speak with DDS/SSA employees if needed.  Based on our current management information data, the current burden information we provided is accurate.  The total burden for this ICR is 218,353 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $14,829,511.  SSA does not charge respondents to complete our applications.
13. 	Annual Cost to the Respondents (Other) 
This collection does not impose a known cost burden on the respondents.   

    14. Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $5,564,769.  This estimate accounts for costs from the following areas:

Description of Cost Factor
Methodology for Estimating Cost
Cost in Dollars*
Designing and Printing the Form
Design Cost + Printing Cost
$7,529
Distribution, Shipping, and Material Costs for the Form
Distribution + Shipping + Material Cost
$0*
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time
GS-9 employee x # of responses x processing time
$5,540,760
Full-Time Equivalent Costs
Out of pocket costs + Other expenses for providing this service
$0*
Systems Development, Updating, and Maintenance
GS-9 employee x man hours for development, updating, maintenance
$16,480.00
Quantifiable IT Costs
Any additional IT costs
$0*
Total

$5,564,769
* We have inserted a $0 amount for cost factors that do not apply to this collection.
SSA is unable to break down the costs to the Federal government further than we already have.  First, since we work with almost every US citizen, we often do bulk mailings and cannot track the cost for a single mailing.  Also, because so many employees have a hand in each aspect of our forms, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations.  However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.
15.	Program Changes or Adjustments to the Information Collection Request
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.
16.  	Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.

17.	Displaying the OMB Approval Expiration Date
SSA is not requesting an exception to the requirement to display the OMB approval expiration date. 

    18. Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B.     	Collections of Information Employing Statistical Methods

	SSA does not use statistical methods for this information collection.