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Fillable Printable Form SSA-5665

Fillable Printable Form SSA-5665

Form SSA-5665

Form SSA-5665

TEACHER QUESTIONNAIRE
ANSWERS FOR TEACHERS OR HOMESCHOOL TEACHERS
ABOUT THE QUESTIONNAIRE
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.
Form SSA-5665-BK (09-2011) ef (09-2011)
Q. WHY DO YOU NEED INFORMATION FROM ME?
A. To decide whether a child qualifies for disability benefits, we use information from both medical and
nonmedical 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.
We appreciate your cooperation, your time, and your effort in completing the questionnaire.
Q. I DO NOT THINK THE CHILD IS DISABLED. SHOULD I COMPLETE THIS
FORM?
Q. IS THIS REQUEST REDUNDANT? WE (OR OTHERS) HAVE ALREADY EVALUATED
THIS CHILD 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 child's impairment(s)
meets the SSA definition of disability, regardless of the child's standing under the IDEA
definition of educational disability.
A. Yes. Under Social Security law, we are responsible for deciding whether this child 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
child'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.
Form SSA-5665-BK (09-2011) ef (09-2011)
PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM
The Privacy Act Statement
Teacher Questionnaire
Collection and Use of Personal Information
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 notneed
to answer these questions unless we display a valid Office of Management and Budgetcontrol
number. We estimate that it will take about 40 minutes to read the instructions, gather thefacts, 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 THECOMPLETED
FORM TO THE REQUESTING OFFICE.You may send comments on our timeestimate above to:
SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.Send onlycommentsrelating to our time
estimate to this address, not the completed form.
Sections 1614 and 1633 of the Social Security Act, as amended, and 20 CFR 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. The information you furnish on this form is voluntary.
However, failure to provide the requested information could prevent our making an accurate and
timely decision on the named claimant’s claim. We rarely use the information you supply for any
purpose other than to make a decision on a claimant’s disability. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security 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 audit or investigative activities necessary to ensure the integrity of Social Security
programs.
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. Information from these matching programs can be used to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs. Explanations about these and other reasons why
information you provide us may be used or given out are available in Systems of Records Notice
60-0089 (Claims Folder Systems). The Notice, additional information about this form, and any
other information regarding our systems and programs are available on-line at
www.socialsecurity.gov
or at your local Social Security office.
IMPORTANT
Form Approved
OMB No. 0960-0646
REQUESTING OFFICE NAME AND ADDRESS
ATTACH LABEL OR TYPE IN CLAIMANT NAME
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:
Student/Teacher Ratio:
Current Instructional Levels Special Ed. Services & Frequency
Math Level:
Written Language
Level:
4.
Form SSA-5665-BK (09-2011) ef (09-2011)
Reading Level:
Is there, or was there, an unusual degree of absenteeism?
5.
Dominant Language:
6.
Any other names by which the child is known:
SOCIAL SECURITY ADMINISTRATION
If yes, please explain:
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.
YesNo
English
Spanish
Other (please specify)
Page 1
1. Comprehending oral instructions
6. Providing organized oral explanations and adequate descriptions
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
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
Form SSA-5665-BK (09-2011) ef (09-2011) Page 2
RATING
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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
4
A serious problem
5
A very serious problem
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
1. Paying attention when spoken to directly
6. Carrying out multi-step instructions
2. Sustaining attention during play/sports activities
3. Focusing long enough to finish assigned activity or task
5. Carrying out single-step instructions
7. Waiting to take turns
8.
9. Organizing own things or school materials
10. Completing class/homework assignments
Changing from one activity to another without being
disruptive
11. Completing work accurately without careless mistakes
12. Working without distracting self or others
13. Working at reasonable pace/finishing on time
Monthly Weekly Daily Hourly
FREQUENCY OF PROBLEM
RATING
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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
5
A very serious problem
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.)
4. Refocusing to task when necessary
13.
Using adequate vocabulary and grammar to express
thoughts/ideas in general, everyday conversation
Form SSA-5665-BK (09-2011) ef (09-2011) Page 4
INTERACTING AND RELATING WITH OTHERS continued on next page
Has it been necessary to implement behavior modification strategies for the child?
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.)
12.
Interpreting meaning of facial expression, body
language, hints, sarcasm
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
1. Playing cooperatively with other children
FREQUENCY OF PROBLEM
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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
5
A very serious problem
NO
YES
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Form SSA-5665-BK (09-2011) ef (09-2011) Page 5
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.)
Moving body from one place to another (e.g., standing, balancing, shifting weight,
bending, kneeling, crouching, walking, running, jumping, climbing)
Moving and manipulating things (e.g., pushing, pulling, lifting, carrying,
transferring objects; coordinating eyes and hands to manipulate small objects)
1.
6. Integrating sensory input with motor output
2.
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
7. Planning, remembering, executing controlled motor movements
RATING
RATING KEY FOR ACTIVITIES LISTED BELOW
Compared to the functioning of same-aged children without impairments, this child has:
III. INTERACTING AND RELATING WITH OTHERS (CONTINUED)
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How much of the child's speech can you, as a familiar
listener, understand on the first attempt?
Very Little
No more
than 1/2
1/2 to 2/3
Almost
All
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
YES, the child has problems functioning in this domain.
Please mark a rating for each activity listed below.
NO problems observed in this domain; functioning appears age-appropriate.
If you selected this block, go directly to Section V.
5
A very serious problem
4
A serious problem
3
An obvious problem
2
A slight problem
1
No Problem
Form SSA-5665-BK (09-2011) ef (09-2011) Page 6
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.)
2. Being patient when necessary
3. Taking care of personal hygiene
4. Caring for physical needs (e.g, dressing, eating)
7. Identifying and appropriately asserting emotional needs
10.
Knowing when to ask for help
1. Handling frustration appropriately
FREQUENCY OF PROBLEM
RATING
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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
5
A very serious problem
Cooperating in, or being responsible for, taking needed
medications
5.
Using good judgement regarding personal safety
and dangerous circumstances
6.
Responding appropriately to changes in own mood (e.
g, calming self)
8.
Using appropriate coping skills to meet daily demands
of school environment
9.
Form SSA-5665-BK (09-2011) ef (09-2011) Page 7
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.)
Does this child frequently miss school due to illness?
If yes, please explain below.
PLEASE PROVIDE YOUR NAME AND TITLE ON NEXT PAGE. Add any remarks as needed.
Specify below, if known.
VI. MEDICAL CONDITIONS AND MEDICATIONS/HEALTH AND PHYSICAL WELL-BEING
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?
Glasses
Hearing Aid
Prosthesis
Nebulizer/Inhaler
Auditory Trainer
Other (please specify)
Assistive
Technology device
Orthopedic devices
Please check any of the following that the child uses:
Is medication prescribed for this child?
Does this child take the medication on a regular basis?
Does this child's functioning change after taking medication?
If yes, please explain below.
Don't knowYesNo
Don't know
Yes
No
Don't know
Yes
No
Yes
No
1
2
3
4
5
6
THANK YOU
Form SSA-5665-BK (09-2011) ef (09-2011) Page 8
Name/Title
Date
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?
Name/Title
Date
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?
This form completed by:
a.m.p.m.
a.m.p.m.
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.
()-
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