Fillable Ssa-5665-bk Teacher Questionnaire

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Ssa-5665-bk Teacher Questionnaire

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Form SSA-5665-BK (06-2018) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 10
OMB No. 0960-0646
Teacher 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 enclosed 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; non-
medical 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 day-
to-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.
Answers For Teachers or Homeschool Teachers About the Questionnaire
Form SSA-5665-BK (06-2018) UF Page 2 of 10
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.
Privacy Act Statement
Collection and Use of Personal Information
PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM
- 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.
Paperwork Reduction Act Statement
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?
How often, and for how long, do you, or did you, see this child?
2.
For what subjects:
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.
3.
Actual Grade Level:
Student/Teacher Ratio:
Current Instructional Levels Special Ed. Services & Frequency
Reading Level:
Math Level:
Written Language
Level:
4.
Is there, or was there, an unusual degree of absenteeism? If yes, please explain:
NoYes
5. Dominant Language:
SpanishEnglish Other
(please specify)
6.
Any other names by which the child is known:
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
1.
Comprehending oral instructions
Rating
2
1
3 4 5
Understanding school and content vocabulary
2.
21 3 4 5
Reading and comprehending written material
3.
21 3 4 5
Comprehending and doing math problems
4.
21 3 4 5
Understanding and participating in class discussions
5.
21 3 4 5
Applying problem-solving skills in class discussions
6.
Providing organized oral explanations and adequate descriptions
21 3 4 5
Expressing ideas in written form
7.
2
1
3 4 5
Learning new material
8.
21 3 4 5
Recalling and applying previously learned material
9.
2
1
3 4 5
10.
2
1
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 Page 5 of 10
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
Rating
1.
Paying attention when
spoken to directly
21 3 4 5
Sustaining attention during
play/sports activities
2.
21 3 4 5
Focusing long enough to
finish assigned activity or task
3.
21 3 4 5
Refocusing to task
when necessary
4.
21 3 4 5
Carrying out
single-step instructions
5.
21 3 4 5
Completing class/
homework assignments
6.
Carrying out
multi-step instructions
21 3 4 5
Waiting to take turns7.
21 3 4 5
Changing from one activity to
another without being disruptive
8.
21 3 4 5
Organizing own things
or school materials
9.
2
1
3 4 5
10.
2
1
3 4 5
Working at reasonable pace/
finishing on time
Completing work accurately
without careless mistakes
11.
21 3 4 5
Working without distracting
self or others
12.
2
1
3 4 5
13.
21 3 4 5
Frequency of Problem
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
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
No Problem
2
A slight problem
3
An obvious problem
4
A serious problem
5
A very serious problem
Rating
1.
Playing cooperatively
with other children
21 3 4 5
Making and keeping friends2.
2
1
3 4 5
Seeking attention appropriately3.
21 3 4 5
Expressing anger appropriately4.
21 3 4 5
Asking permission
appropriately
5.
21 3 4 5
Introducing and maintaining relevant
and appropriate topics of conversation
6.
Following rules
(classroom, games, sports)
21 3 4 5
Respecting/obeying adults
in authority
7.
21 3 4 5
Relating experiences
and telling stories
8.
21 3 4 5
Using language appropriate
to the situation and listener
9.
21 3 4 5
10.
21 3 4 5
Using adequate vocabulary and grammar
to express thoughts/ideas in general,
everyday conversation
Taking turns in conversation11.
21 3 4 5
Interpreting meaning of facial expression,
body language, hints, sarcasm
12.
2
1
3 4 5
13.
21 3 4 5
Frequency of Problem
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Weekly
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Daily
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
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.
Has it been necessary to implement behavior modification strategies for the child?
NoYes
Interacting and Relating with Others continued on next page
Form SSA-5665-BK (06-2018) UF Page 7 of 10
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
No Problem
2
A slight problem
3
An obvious problem
4
A serious problem
5
A very serious problem
Rating
1.
Moving body from one place to another (e.g., standing, balancing, shifting
weight, bending, kneeling, crouching, walking, running, jumping, climbing
21 3 4 5
Moving and manipulating things (e.g., pushing, pulling, lifting, carrying,
transferring objects; coordinating eyes and hands to manipulate small objects
2.
21 3 4 5
Demonstrating strength, coordination, dexterity in activities or tasks3.
21 3 4 5
Managing pace of physical activities or tasks4.
21 3 4 5
Showing a sense of body's location and movement in space5.
21 3 4 5
6. Integrating sensory input with motor output
21 3 4 5
Planning, remembering, executing controlled motor movements7.
2
1 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.)
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.)
When the topic of conversation is known
When the topic of conversation is unknown2.
1.
How much of the child's speech can you, as a familiar listener,
understand after repetition and/or rephrasing?
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
Form SSA-5665-BK (06-2018) UF Page 8 of 10
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
No Problem
2
A slight problem
3
An obvious problem
4
A serious problem
5
A very serious problem
Rating
1. Handling frustration appropriately
21 3 4 5
Frequency of Problem
Monthly
Weekly
Daily
Hourly
Being patient when necessary2.
21 3 4 5
Monthly
Weekly
Daily
Hourly
Taking care of personal hygiene3.
21 3 4 5
Monthly
Weekly
Daily
Hourly
Caring for physical needs
(e.g., dressing, eating)
4.
21 3 4 5
Monthly
Weekly
Daily
Hourly
Cooperating in, or being responsible for,
taking needed medications
5.
21 3 4 5
Monthly
Weekly
Daily
Hourly
Using good judgment regarding personal
safety and dangerous circumstances
6.
21 3 4 5
Monthly
Weekly
Daily
Hourly
Identifying and appropriately asserting
emotional needs
7.
21 3 4 5
Monthly
Weekly
Daily
Hourly
Responding appropriately to changes in
own mood (e.g., calming self)
8.
21 3 4 5
Monthly
Weekly
Daily
Hourly
Using appropriate coping skills to meet
daily demands of school environment
9.
21 3 4 5
Monthly
Weekly
Daily
Hourly
Knowing when to ask for help10.
21 3 4 5
Monthly
Weekly
Daily
Hourly
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
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?
1.
2.
Please check any of the following that the child uses:
Glasses
Hearing Aid
Prosthesis Other
Auditory Trainer
Nebulizer/Inhaler
Orthopedic devices
Assistive Technology device
(please specify)
Is medication prescribed for this child? Specify below, if known.
3.
NoYes Don't Know
Does this child take the medication on a regular basis?4.
Don't KnowNoYes
5.
Does this child's functioning change after taking medication?
Don't KnowNoYes
If yes, please explain below
If yes, please explain below
6.
Does this child frequently miss school due to illness?
NoYes
Please Provide Your Name and Title on Next Page. Add Any Remarks as Needed.
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.)
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?
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?
Name/Title Date
Thank You
( )
a.m.
p.m.
( )
p.m.
a.m.
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Completed 15 November 2019

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