Form SSA-5666 Request for Administrative Information

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

Date(s):

services? If yes, to whom?

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

D

D

2

3

4

5

6

7

8

9

10

11

12

D

D

D

D

D

D

D

D

D

D

D

5. Educational Disabilities, if any:

0

Mental Retardation/Mentally Impaired/Intellectually Limited

0
0
0
0

Heanng lmpairmenVDeafness
Speech or Language Impairment
Visual Impairment/Blindness

Replace
with:
Intellectual
Disability

Emotional Disturbance/Behavior Disorder

0

Orthopedic Impairment

0
0

Autism

0

Other Health Impairment (please specify)

0

Specific Leaming Disability (please specify)

0

Developmental Delay (please specify)

0

Multiple Disabilities (please specify)

Traumatic Brain Injury

6. Placement and Related Services (Check all that apply):

0
0

Regular Education, no special instruction
Special Ed. Instruction:
Inclusion - Sp. instr. in regular class
Resource Room

0
0

Self-contained, regular school

0

Residential

0
0
0
0

Therapies, etc:
Occupational Therapy
Physical Therapy
Speech - Language Therapy
Counselling (please specify)

Self-contained, special school
Special school, non-public

Form

Hours/week:

0

Other (please specify)

PLEASE PROVIDE YOUR NAME AND TITLE ON NEXT PAGE
SSA-5666 (09-2011) ef (09-2011)
Page 1

Hours/week:

Privacy Act Statement
Request for Administrative Information
Collection and Use of Personal Information
Sections 205(a) and 223(a) and (d), and Sections 1614, 1631(e)(1), and 1633 of the Social Security Act,
as amended, and 20 CFR 404.1513, 416.913, and 416.924a(a), authorize us to collect this information.
We will use the information you provide to make a decision on the named claimant’s claim.
Furnishing us the information is voluntary. However, failing to provide all or part of the requested
information may prevent our making an accurate and timely decision on the claim.
We rarely use the information you supply for any purpose other than to make a decision regarding a
claimant’s disability. However, we may use it for the administration and integrity of our programs. We
may also disclose the information to another person or to another agency in accordance with approved
routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing a person’s rights to our benefits and
coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local levels; and
4. To facilitate statistical research, audit, and investigatory activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract
with us).
We may also use the information you provide in computer-matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies. We use the
information from these programs to establish or verify a person’s eligibility for federally funded or
administered programs and for repayment of incorrect payments or delinquent debts under these
programs.
A complete list of routine uses of this information is available in our Privacy Act System of Records
Notice 60-0089 (Claims Folder Systems), entitled, Claims Folders Systems. Additional information
about this and other system of records notices is available on-line at www.socialsecurity.gov, or at your
local Social Security office.