Addendum to the Supporting Statement for 0960-0646

ADDENDUM TO THE SUPPORTING STATEMENT

Teacher Questionnaire, Form SSA-5665-BK

Request for Administrative Information, Form SSA-5666

20 CFR Section 416.924(a) (2)

OMB No. 0960-0646

Changes to the SSA-5665-BK: Teacher Questionnaire

Change 1: We are revising the language in the heading of the cover page.

• Old Language:

ANSWERS FOR TEACHERS OR HOME-SCHOOL TEACHERS ABOUT THE QUESTIONNAIRE

• New Language:

ANSWERS FOR TEACHERS, HOMESCHOOL TEACHERS, OR INSTRUCTORS ABOUT THE QUESTIONNAIRE

Justification 1: We are revising the language to address all possible recipients of the form

Change 2: We are revising the language in the first paragraph of the cover page.

• Old Language:

One of your current or former students has filed a claim for disability benefits. We need information from you to help us make our decision. Please complete the enclosed questionnaire.

• New Language:

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.

Justification 2: We are revising the language to indicate the scope of applicability of the form, because it can be used in title XVI cases of applicants for SSI based on disability (under and over age 18); in title II cases involving child-in-care claims (age 15½ to age 18); and in title II disabled adult child claims (under age 22).

Change 3: We are revising the language under section Q. WHY DO YOU NEED INFORMATION FROM ME?

• Old Language:

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.

• New Language:

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 under the SSI or DIB rules, but it is very important to us.

Justification 3: We are revising the language to make clear to the reader that the form applies to both title XVI and title II individuals, and also to eliminate somewhat repetitive text.

Change 4: We are changing the word “child” to “person” in the following section Q. heading: IS THIS REQUEST REDUNDANT? WE (OR OTHERS) HAVE ALREADY EVALUATED THIS PERSON UNDER THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA).

Justification 4: We are changing the word to make the heading applicable to individuals under and over age 18.

Change 5: We are changing the word “child’s” to“people” in the paragraph A. response to the above section Q. heading.

Justification 5: We are changing the word to make the text applicable to individuals under and over age 18.

Other Minor Revisions to the Collection Instrument for the SSA-5665-BK and SSA-5666

We the Privacy Act Statement on the SSA-5665-BK and the SSA-5666 to include the title II statutory and regulatory authorities for collecting information in title II (child-in-care and disabled adult child) claims for benefits based on an individual’s disability.

In accordance with the systematic review of SSA’s Privacy Act Statements on agency forms by the Office of the General Counsel (OGC), we are making other minor revisions to the Privacy Act Statement based on the most recent text provided by OGC.