Information Collection

SSA-5665-BK (Teachers)

IC 197497 under ICR 202607-0960-002 · OMB 0960-0646.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5665-BK (Elect Teacher Questionnaire SSA-5665-BK (Teachers)	Form and Instruction
Disability Case Development - paper cover letter template -Revised.pdf	Other-Cover Letter
Disability Case Development electronic cover letter - Revised.pdf	Other-Cover Letter
Revised PA Statement-SSA-5665.docx	Other-Revised PA Statement
Revised PA Statement-Disability Case Development- Revised.docx	Other-Revised PA Statement
SSA-5665-BK (Elect Teacher Questionnaire SSA-5665-Revised.pdf	Form and Instruction
SSA--5665 - current.pdf SSA-5665-BK - Teacher Questionnaire -Current	IC Document
Disability Case Development - paper cover letter template -current.pdf Disability Case Development- Paper Cover Letter Template-Current	IC Document
Disability Case Development electronic cover letter - current.pdf Disability Case Development Electronic Cover Letter -current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.1103(f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-5665-BK (Electronic)	Yes	Yes	Fillable Fileable Signable
Other-Cover Letter		No		Paper Only
Other-Cover Letter		Yes	Yes	Fillable Printable
Other-Revised PA Statement		Yes	Yes	Fillable Fileable Signable
Other-Revised PA Statement		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 211,487

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	211,487	-35,052	246,539
Annual IC Time Burden (Hours)	246,735	82,376	164,359
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5665-BK - Teacher Questionnaire -Current		07/01/2026
Disability Case Development- Paper Cover Letter Template-Current		07/28/2026
Disability Case Development Electronic Cover Letter -current		07/28/2026

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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