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pdfTEACHER QUESTIONNAIRE
ANSWERS FOR TEACHERS, HOMESCHOOL TEACHERS, OR
INSTRUCTORS ABOUT THE QUESTIONNAIRE
One of your current or former students has applied for title XVI Supplemental Security Income (SSI)
payments based on disability, or for title II disability status as a Disabled Minor Child, or for title II
Social Security Disability Insurance Benefits (DIB) as a Disabled Adult Child. We need information
from you to help us make our disability determination. Please complete the enclosed questionnaire.
Q. WHY DO YOU NEED INFORMATION FROM ME?
A. To decide whether a child (under age 18) or young adult (age 18 or older)—both hereafter referred to
as “person”—is disabled according to the Social Security Act, we use information from both medical and
nonmedical sources. Medical sources include doctors and other health care professionals; non-medical
sources include teachers, training instructors, and other people who spend time with, and know, the
person well. The information you provide about this person’s day-to-day functioning in school or another
setting is important because it will help us to determine the effects of the person’s impairment and to
compare the person’s functioning to that of others the same age who do not have impairments. We need
this information from you even if you have taught (or did teach) the person for only a short time. Your
information is not the only information we will be considering when we decide if the person qualifies for
SSI or DIB, but it is very important to us.
Q. IS THIS REQUEST REDUNDANT? WE (OR OTHERS) HAVE ALREADY EVALUATED
THIS PERSON 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 person's impairment(s) meets
the SSA definition of disability, regardless of the person's standing under the IDEA definition of
educational disability.
Q. I DO NOT THINK THE PERSON IS DISABLED. SHOULD I COMPLETE THIS FORM?
A. Yes. Under Social Security law, we are responsible for deciding whether this person 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 person'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 checkboxes 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.
Form SSA-5665-BK
The Privacy and Paperwork Reduction Acts
Sections 202 and 223(a) and (d), and Sections 221, 1614, and 1633 of the Social Security Act, as
amended, and 20 CFR 404.1513 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 level; 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 benefit 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.
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 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 1, 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.
PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.
Form SSA-5665-BK
Form Approved
OMB No. 0960-0646
SOCIAL SECURITY ADMINISTRATION
ATTACH LABEL OR TYPE IN CLAIMANT NAME
REQUESTING OFFICE NAME AND ADDRESS
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?
2. How often, and for how long, do you, or did you, see this child?
For what subjects:
3. Actual Grade Level:
Current Instructional Levels
Special Ed. Services & Frequency
Reading Level:
Student/Teacher Ratio:
Math Level:
Written Language
Level:
4. Is there, or was there, an unusual degree of absenteeism?
5. Dominant Language:
English
Spanish
No
Yes
If yes, please explain:
Other (please specify)
6. Any other names by which the child is known:
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.
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 1
I. ACQUIRING AND USING INFORMATION
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section II.
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
5
A very serious problem
4
A serious problem
RATING
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
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5
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2
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2
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2
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1
2
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5
1. Comprehending oral instructions
2. Understanding school and content vocabulary
3. Reading and comprehending written material
4. Comprehending and doing math problems
5. Understanding and participating in class discussions
6. Providing organized oral explanations and adequate descriptions
7. Expressing ideas in written form
8. Learning new material
9. Recalling and applying previously learned material
10. Applying problem-solving skills in class discussions
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 (09-2011) ef (09-2011)
Page 2
II. ATTENDING AND COMPLETING TASKS
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section III.
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
RATING
5
A very serious problem
FREQUENCY OF PROBLEM
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
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5
Monthly
Weekly
Daily
Hourly
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5
Monthly
Weekly
Daily
Hourly
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5
Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
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Hourly
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Monthly
Weekly
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Hourly
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Monthly
Weekly
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Hourly
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Monthly
Weekly
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Hourly
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Monthly
Weekly
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Hourly
1. Paying attention when spoken to directly
2. Sustaining attention during play/sports activities
3. Focusing long enough to finish assigned activity or task
4. Refocusing to task when necessary
5. Carrying out single-step instructions
6. Carrying out multi-step instructions
7. Waiting to take turns
8.
Changing from one activity to another without being
disruptive
9. Organizing own things or school materials
10. Completing class/homework assignments
11. Completing work accurately without careless mistakes
12. Working without distracting self or others
13. Working at reasonable pace/finishing on time
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 (09-2011) ef (09-2011)
Page 3
III. INTERACTING AND RELATING WITH OTHERS
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section IV.
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
RATING
5
A very serious problem
FREQUENCY OF PROBLEM
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
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2
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5
Monthly
Weekly
Daily
Hourly
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2
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Monthly
Weekly
Daily
Hourly
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2
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5
Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
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Hourly
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Monthly
Weekly
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Hourly
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Monthly
Weekly
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Hourly
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Monthly
Weekly
Daily
Hourly
1. Playing cooperatively with other children
2. Making and keeping friends
3. Seeking attention appropriately
4. Expressing anger appropriately
5. Asking permission appropriately
6. Following rules (classroom, games, sports)
7. Respecting/obeying adults in authority
8. Relating experiences and telling stories
9. Using language appropriate to the situation and listener
10.
Introducing and maintaining relevant and appropriate
topics of conversation
11. Taking turns in a conversation
Interpreting meaning of facial expression, body
language, hints, sarcasm
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
12.
Using adequate vocabulary and grammar to express
thoughts/ideas in general, everyday conversation
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
13.
NO
Has it been necessary to implement behavior modification strategies for the child?
YES
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.
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.)
INTERACTING AND RELATING WITH OTHERS continued on next page
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 4
III. INTERACTING AND RELATING WITH OTHERS (CONTINUED)
Very Little
How much of the child's speech can you, as a familiar
listener, understand on the first attempt?
Almost
All
1/2 to 2/3
No more
than 1/2
1. When the topic of conversation is known?
2. When the topic of conversation is unknown?
How much of the child's speech can you, as a familiar listener,
understand after repetition and/or rephrasing?
IV. MOVING ABOUT AND MANIPULATING OBJECTS
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section V.
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)
2.
Moving and manipulating things (e.g., pushing, pulling, lifting, carrying,
transferring objects; coordinating eyes and hands to manipulate small objects)
1
2
3
4
5
1
2
3
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5
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5
3. Demonstrating strength, coordination, dexterity in activities or tasks
4. Managing pace of physical activities or tasks
5. Showing a sense of body's location and movement in space
6. Integrating sensory input with motor output
7. Planning, remembering, executing controlled motor movements
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 (09-2011) ef (09-2011)
Page 5
V. CARING FOR HIMSELF OR HERSELF
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section VI.
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
RATING
5
A very serious problem
FREQUENCY OF PROBLEM
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
1
2
3
4
5
Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
Daily
Hourly
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Monthly
Weekly
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Hourly
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Monthly
Weekly
Daily
Hourly
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5
Monthly
Weekly
Daily
Hourly
1. Handling frustration appropriately
2. Being patient when necessary
3. Taking care of personal hygiene
4. Caring for physical needs (e.g, dressing, eating)
Cooperating in, or being responsible for, taking needed
medications
Using good judgement regarding personal safety
6.
and dangerous circumstances
5.
7. Identifying and appropriately asserting emotional needs
Responding appropriately to changes in own mood
(e.g, calming self)
Using appropriate coping skills to meet daily demands
9.
of school environment
8.
10. Knowing when to ask for help
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? Is so,
what kind and how often? (Continue on the last page if needed.)
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 6
VI. MEDICAL CONDITIONS AND MEDICATIONS/HEALTH AND PHYSICAL WELL-BEING
1 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?
2 Please check any of the following that the child uses:
Glasses
Nebulizer/Inhaler
Assistive
Technology device
Hearing Aid
Auditory Trainer
Orthopedic devices
Prosthesis
Other (please specify)
3 Is medication prescribed for this child?
No
Yes
Don't know
Specify below, if known.
4 Does this child take the medication on a regular basis?
No
Yes
Don't know
5 Does this child's functioning change after taking medication?
If yes, please explain below.
No
Yes
Don't know
6
Yes
Does this child frequently miss school due to illness?
No
If yes, please explain below.
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.)
PLEASE PROVIDE YOUR NAME AND TITLE ON NEXT PAGE. Add any remarks as needed.
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 7
VII. 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:
Date
Name/Title
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?
a.m.
(
)
-
p.m.
Date
Name/Title
If we need more information about this child,
Is there a phone number where we can reach you?
a.m.
Is there a best time to call you?
(
THANK YOU
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 8
)
p.m.
-
| File Type | application/pdf |
| File Title | S5665.xft |
| Author | 838994 |
| File Modified | 2014-06-11 |
| File Created | 2014-06-11 |