Supporting Statement 0960-0646

Supporting Statement for

Teacher Questionnaire, Form SSA-5665-BK

Request for Administrative Information, Form SSA-5666

ODAR Cover Letter to Teacher Questionnaire, HA-85

ODAR Cover Letter to Request for Administrative Information, HA-86

OMB No. 0960-0646

A. Justification

1. Introduction/Authoring Laws and Regulations

Sections 202 and 223(a) and (d) of the Social Security Act (Act) require the Social Security Administration (SSA) to apply a statutory definition of disability for minor children (individuals between the age of 15.5 to 18 years) in Title II child-in-care claims, and for adult children (under age 22 years) claiming Title II Childhood Disability Benefits. Section 1614(a)(3)(C) of the Act, as amended by Public Law 104-19, requires SSA to apply a statutory definition of disability for children (individuals under the age of 18 years) applying for Title XVI Supplemental Security Income (SSI) payments based on disability. Sections 221 and 1633 of the Act allow the Commissioner of SSA to make appropriate or necessary administrative and other arrangements to carry out the functions of the agency under Titles II and XVI, respectively.

20 CFR 404.1513 and 416.924(a) of the Code of Federal Regulations require SSA to consider all relevant evidence in the case record when determining whether a child has a disability under Title II or XVI of the Act (initial, reconsideration, or continuing disability determination). This may include medical evidence, school records, and employment history.

20 CFR 416.924(a)(2) requires that when determining the effects of the child’s impairment(s), SSA 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. Education programs are an important source of evidence and often provide formal assessment results and other information from a variety of disciplines. Evidence from educational programs varies a great deal in format, content, reliability, and usefulness. The need exists, therefore, for an information collection instrument that ensures a degree of uniformity and consistency in the quantity and quality of information received about children’s impairment-related limitations. The same need occurs in Title II cases involving disabled minor children and disabled adult children. We use Forms SSA-5665-BK and SSA-5666 for this purpose.

2. Description of Collection

When determining the effects of a child’s impairment(s), SSA obtains information about the child’s functioning from teachers, parents, and others who have the opportunity to observe the child on a daily basis. SSA uses Forms SSA-5665-BK and SSA-5666 to make one-time requests for teacher reports, results of formal testing, therapy progress notes, individualized education programs, and other records of a child’s educational aptitude and achievement. The respondents are teachers and other education personnel.

Forms SSA-5665 and SSA-5666 are available electronically to school and training program administrators on SSA’s website, www.socialsecurity.gov/schools. State Disability Determination Services (DDS) or SSA may send a request for completion of the SSA-5665-BK to a child’s local school administrative office or training program, which refers the request to the child’s teacher(s), who then accesses the form through the link. The teacher(s) forwards the completed SSA-5665 to the school’s or training program’s administrative office, which uploads it to SSA’s Electronic Records Express (ERE) system.

The DDS or SSA may send a request for completion of the SSA-5666 and copies of the child’s school records to the central or local administrative school office, depending on which office maintains the child’s individual academic records. The administrative office or training program can also upload the child’s records via ERE. Although the SSA-5665-BK and SSA-5666 are available for online completion, some teachers and school personnel may print and manually complete the forms, then fax or mail them to the requesting DDS or SSA office.

3. Use of Information Technology To Collect the Information

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created Internet versions of the SSA-5665 and SSA-5666. Based on our data, we estimate that approximately 98 percent of respondents use the electronic versions of the SSA-5665 and the SSA-5666.

4. Why We Cannot Use Duplicate Information

The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar information.

5. Minimizing Burden on Small Respondents

This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting It Less Frequently

If we were not to use Forms SSA-5665-BK and SSA-5666, the cost of the Title XVI and Title II disability programs would increase because: (1) non-uniform documentation of information about children’s functioning in school settings or training programs would be less efficient, less reliable, and less clear for purposes of quality assurance and any other reviews. Since we only collect the information once, we cannot collect it less frequently.

There are no technical or legal obstacles to burden reduction.

7. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public

SSA published the 60-day advance Federal Register Notice on May 9, 2014 at 79 FR 26798. We received no public comments. We published the 30-day Notice on July 23, 2014 at 79 FR 42863. If we receive any comments in response to this Notice, we will forward them to OMB.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 422; 5 U.S.C. 552 (Freedom of Information Act);

5 U.S.C. 552a (Privacy Act of 1974); and OMB Circular, No. A-130.

11. Justification for Sensitive Questions

The collection contains information that may disclose sensitive material in that it describes limitations imposed on a child’s daily functioning or impairment(s). However, SSA cannot make a disability determination without obtaining a description of the child’s ability to function on a day-to-day basis.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-5665-BK (electronic)	368,098	1	40	245,399
SSA-5665-BK (paper)	2,562	1	40	1,708
SSA-5666 (electronic)	137,590	1	30	68,795
SSA-5666 (paper)	1,843	1	30	922
Totals	510,093	-	-	316,824

The total burden for this information collection request is 316,823 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $14,132. This estimate is a projection of the costs for printing and distributing the paper collection instrument and for collecting the information.

The estimated cost to the Federal Government to collect the information electronically is negligible. Because the cost of maintaining the system that collects information is accounted for within the cost of maintaining all of SSA’s automated systems, it is not possible to calculate the cost associated with just one Internet application.

15. Program Changes or Adjustments to the Information Collection Request

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. Since the 2011 clearance, SSA has made the SSA-5666 available electronically, accounting for the reduction in usage of the paper version of the form.

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16. Plans for Publication of Information Collection Results

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date

For the paper Forms SSA-5665-BK and SSA-5666, we will not publish the OMB approval expiration date. OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so that SSA would not have to destroy stocks of otherwise usable forms with expired OMB approval dates, thereby avoiding Government waste.

For the Internet version of Forms SSA-5665-BK and SSA-5666, SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. Exceptions to Certification Statement

SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.