Fillable Ssa 5666 Ssa-5666 Request For Administrative Information (U.S. Social Security Administration)

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Ssa 5666 Ssa-5666 Request For Administrative Information (U.S. Social Security Administration)

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FORM SSA-5666 (04-2018) UF
Discontinue Prior Editions
Page 1 of 2
OMB No. 0960-0646
SOCIAL SECURITY ADMINISTRATION
REQUESTING OFFICE NAME AND ADDRESS 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 services?
If yes, to whom?
Date(s):
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
Other Health Impairment (please specify)
Specific Learning Disability (please specify)
Developmental Delay (please specify)
Multiple Disabilities (please specify)
6. Placement and Related Services (Check all that apply):
Special Ed. Instruction
Regular Education, no special instruction
Hours/week:
Inclusion - Sp. instr. in regular class
Resource Room
Self-contained, special school
Self-contained, regular school
Residential
Special school, non-public
Therapies, etc:
Occupational Therapy
Physical Therapy
Counselling (please specify)
Speech - Language Therapy
Other (please specify)
Hours/week:
PLEASE PROVIDE YOUR NAME AND TITLE ON THE NEXT PAGE
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.
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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
Name/Title
Name/Title (If more than one person helped complete this form) Date
Date Phone
Phone
THANK YOU
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.
Page 2 of 2 FORM SSA-5666 (04-2018) UF
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Completed 26 July 2020

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