Teacher Questionnaire; Request for Administrative Information

Forms and Documents

Document Name	Status
Form SSA-5665-BK SSA-5665-BK (paper) Form and Instruction	Modified
Form SSA-5665-BK (Elect SSA-5665-BK (electronic) Form and Instruction	New
Form SSA-5666 SSA-5666 Form and Instruction	Modified
0646_Addendum.doc Supplementary Document	2011-07-05
Supporting Statement--0646(revised).doc Supporting Statement A	2011-07-05

IC Document Collections

IC ID	Document Title	Status
9683	SSA-5665-BK (paper) Form and Instruction	Modified
197497	SSA-5665-BK (electronic) Form and Instruction	New
183366	SSA-5666 Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0646	ICR Reference No: 201103-0960-016
Status: Historical Active	Previous ICR Reference No: 200804-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Teacher Questionnaire; Request for Administrative Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2011
	Date Received in OIRA: 07/14/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved	09/30/2011
Responses	797,000	0	1,233,000
Time Burden (Hours)	465,167	0	359,750
Cost Burden (Dollars)	0	0	0

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Abstract: When determining the effects of a child's impairment(s), SSA must obtain information about the child's functioning from teachers, parents, and others who have the opportunity to observe the child on a day-to-day basis. SSA obtains results of formal testing, teacher reports, therapy progress notes, Individualized Education Programs, and other records of a child's educational aptitude and achievement on the SSA-5665 and SSA-5666. The respondents are parents, teachers, and other Education personnel.

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Authorizing Statute(s): US Code: 42 USC 1382c Name of Law: Social Security Act
   US Code: 42 USC 1383b Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 19175	04/06/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 38448	06/30/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
SSA-5665-BK (paper)	SSA-5665-BK	Teacher Questionnaire
SSA-5666	SSA-5666	Request for Administrative Information
SSA-5665-BK (electronic)	SSA-5665-BK (Electronic)	Teacher Questionnaire

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	797,000	1,233,000	0	388,581	-824,581	0
Annual Time Burden (Hours)	465,167	359,750	0	259,054	-153,637	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There has been a decrease in burden hours. This change stems from a decrease in the number of child applications from birth to age 18. There has been in increase in burden hours. This change also stems from an increase in the completion time from 20 minutes to 40 minutes for form SSA-5665-BK, and 15 minutes to 30 minutes for form SSA-5666.

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Annual Cost to Federal Government: $167,720

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/14/2011

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