Form Ssa 5665 Bk – Fill Out and Use This PDF

The SSA-5665-BK form, commonly known as the Teacher Questionnaire, serves as a critical tool for the Social Security Administration to gather information from educators about a student's functioning in a school setting. This information is essential in the decision-making process for determining a child's eligibility for disability benefits. By providing detailed insights into the child's daily activities and comparing their functioning to peers without impairments, teachers play a vital role in helping assess the child's level of disability. Click the button below to start the process of filling out this crucial form.

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Form Ssa 5665 Bk PDF Details

In the intricate landscape of supporting children with disabilities, the Form SSA-5665-BK emerges as a vital tool in the evaluation process for disability benefits within the United States. This form, also referred to as the Teacher Questionnaire, plays a pivotal role by gathering essential insights from teachers or homeschool instructors about a student's daily functioning and capabilities in an educational setting. The Social Security Administration (SSA) utilizes this form to acquire detailed observations that contribute significantly to the determination of a child's eligibility for disability benefits. These observations encompass various domains of a child’s functioning including their ability to acquire and use information, attend and complete tasks, among others, compared to their peers without impairments. The SSA underscores the importance of this information, distinguishing between the educational parameters of the Individuals With Disabilities Education Act (IDEA) and the SSA's disability criterion, which are distinct in definition and purpose. Completing the form requires a thoughtful examination of the student's abilities, suggesting the necessity for educators to comprehensively report on the child's academic performance and behaviors, regardless of the quantity of time spent with the student. This process not only aids in making a precise and fair decision regarding the child's benefit claims but also respects the privacy and sensitive handling of the information provided by educators. Thus, the participation of teachers in filling out the Form SSA-5665-BK is instrumental in shaping the outcomes for children seeking disability benefits, ensuring a process rooted in thorough assessment and fairness.

Question	Answer
Form Name	Form Ssa 5665 Bk
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	ssa 5665, ssa teacher questionnaire, teacher questionnaire search, 5665

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Form SSA-5665-BK (06-2018) UF
Discontinue Prior Editions	Page 1 of 10
Social Security Administration	OMB No. 0960-0646

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 a decision. Please complete the enclose questionnaire.

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 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.

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.

Q. I Do Not Think The Child Is Disabled. Should I Complete This Form?

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 check boxes 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 (06-2018) UF

Page 2 of 10

Privacy Act Statement

Collection and Use of Personal Information

Sections 202, 223 and 1631(e) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and timely decision on the named claimant’s eligibility for benefits.

We will use the information to make a determination of eligibility for benefits. We may also share your information for the following purposes, called routine uses:

1.To specified business and other community members and Federal, State, and local agencies for verification of eligibility for benefits under section 1631(e) of the Act; and

2.To Federal, State, or local agencies for administering cash or non-cash income maintenance or health maintenance programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer

matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089, entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

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 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 3, 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 (06-2018) UF
Discontinue Prior Editions	Page 3 of 10
Social Security Administration	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:

How long have you known, or did you know, this child?

How often, and for how long, do you, or did you, see this child?

For what subjects:

Actual Grade Level:

Student/Teacher Ratio:

Current Instructional Levels

Special Ed. Services & Frequency

Reading Level:

Math Level:

Written Language

Level:

Is there, or was there, an unusual degree of absenteeism?	Yes	No If yes, please explain:

Dominant Language:	English	Spanish	Other (please specify)

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 (06-2018) UF	Page 4 of 10

1. Acquiring and Using Information

NO problems observed in this domain; functioning appears age-appropriate.

If you selected this block, go directly to Section 2.

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	2	3	4			5
No Problem		A slight problem	An obvious problem	A serious problem		A very serious problem

						Rating

1.	Comprehending oral instructions			1	2	3	4	5
1.	Comprehending oral instructions

2.	Understanding school and content vocabulary			1	2	3	4	5
2.	Understanding school and content vocabulary

3.	Reading and comprehending written material			1	2	3	4	5
3.	Reading and comprehending written material

4.	Comprehending and doing math problems			1	2	3	4	5
4.	Comprehending and doing math problems

5.	Understanding and participating in class discussions			1	2	3	4	5
5.	Understanding and participating in class discussions

6.				1	2	3	4	5
6.	Providing organized oral explanations and adequate descriptions

7.	Expressing ideas in written form			1	2	3	4	5
7.	Expressing ideas in written form

8.	Learning new material			1	2	3	4	5
8.	Learning new material

9.	Recalling and applying previously learned material			1	2	3	4	5
9.	Recalling and applying previously learned material

10.	Applying problem-solving skills in class discussions			1	2	3	4	5
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 (06-2018) UF	Page 5 of 10

2. Attending and Completing Tasks

NO problems observed in this domain; functioning appears age-appropriate.

If you selected this block, go directly to Section 3.

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	2			3			4		5
No Problem		A slight problem	An obvious problem					A serious problem A very serious problem

					Rating			Frequency of Problem

1.	Paying attention when		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
1.	Paying attention when		1	2	3	4	5
	spoken to directly

2.	Sustaining attention during		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
2.	play/sports activities

3.	Focusing long enough to		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
3.	finish assigned activity or task

4.	Refocusing to task		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
4.	when necessary

Carrying out	1 2 3 4 5	Monthly Weekly	Daily	Hourly
single-step instructions

6.	Carrying out	1	2	3	4	5	Monthly	Weekly	Daily	Hourly
6.	multi-step instructions

7.	Waiting to take turns	1	2	3	4	5	Monthly	Weekly	Daily	Hourly
7.	Waiting to take turns

8.	Changing from on activity to	1	2	3	4	5	Monthly	Weekly	Daily	Hourly
8.	another without being disruptive

9.	Organizing own things	1	2	3	4	5	Monthly	Weekly	Daily	Hourly
9.	or school materials

10.	Completing class/	1	2	3	4	5	Monthly	Weekly	Daily	Hourly
10.	homework assignments

11.	Completing work accurately	1	2	3	4	5	Monthly	Weekly	Daily	Hourly
11.	without careless mistakes

12.	Working without distracting	1	2	3	4	5	Monthly	Weekly	Daily	Hourly
12.	self or others

13.	Working at reasonable pace/	1	2	3	4	5	Monthly	Weekly	Daily	Hourly
13.	finishing on time

Form SSA-5665-BK (06-2018) UF	Page 6 of 10

3. Interacting and Relating with Others

NO problems observed in this domain; functioning appears age-appropriate.

If you selected this block, go directly to Section 4.

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	2	3				4			5
No Problem		A slight problem An obvious problem				A serious problem			A very serious problem
					Rating			Frequency of Problem

1.	Playing cooperatively		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
1.	Playing cooperatively		1	2	3	4	5
	with other children

2.	Making and keeping friends		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
2.	Making and keeping friends

3.	Seeking attention appropriately		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
3.	Seeking attention appropriately

4.	Expressing anger appropriately		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
4.	Expressing anger appropriately

5.	Asking permission		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
5.	appropriately

6.	Following rules		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
6.	(classroom, games, sports)

7.	Respecting/obeying adults		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
7.	in authority

8.	Relating experiences		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
8.	and telling stories

9.	Using language appropriate		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
9.	to the situation and listener

10.	Introducing and maintaining relevant		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
10.	and appropriate topics of conversation

11.	Taking turns in conversation		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
11.	Taking turns in conversation

12.	Interpreting meaning of facial expression,		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
12.	body language, hints, sarcasm

13.

Using adequate vocabulary and grammar	1 2 3 4 5	Monthly Weekly Daily Hourly
to express thoughts/ideas in general,	1 2 3 4 5	Monthly Weekly Daily Hourly
to express thoughts/ideas in general,
everyday conversation

Has it been necessary to implement behavior modification strategies for the child? Yes No

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.

Interacting and Relating with Others continued on next page

Form SSA-5665-BK (06-2018) UF

Page 7 of 10

3. Interacting and Relating with Others (Continued)

How much of the child's speech can you, as a familiar listener,	Very	No more	1/2 to	Almost
understand on the first attempt?	Little	than 1/2	2/3	All

When the topic of conversation is known

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?

4. Moving About and Manipulating Objects

NO problems observed in this domain; functioning appears age-appropriate.

If you selected this block, go directly to Section 5.

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	2	3	4			5
No Problem		A slight problem	An obvious problem	A serious problem	A very serious problem
							Rating

1.	Moving body from one place to another (e.g., standing, balancing, shifting				1	2	3	4	5
1.	weight, bending, kneeling, crouching, walking, running, jumping, climbing

2.	Moving and manipulating things (e.g., pushing, pulling, lifting, carrying,				1	2	3	4	5
2.	transferring objects; coordinating eyes and hands to manipulate small objects

3.	Demonstrating strength, coordination, dexterity in activities or tasks				1	2	3	4	5
3.

4.	Managing pace of physical activities or tasks				1	2	3	4	5
4.	Managing pace of physical activities or tasks

5.	Showing a sense of body's location and movement in space				1	2	3	4	5
5.	Showing a sense of body's location and movement in space

6.	Integrating sensory input with motor output				1	2	3	4	5
6.	Integrating sensory input with motor output

7.	Planning, remembering, executing controlled motor movements				1	2	3	4	5
7.	Planning, remembering, executing controlled motor movements

Form SSA-5665-BK (06-2018) UF	Page 8 of 10

5. Caring for Himself or Herself

NO problems observed in this domain; functioning appears age-appropriate.

If you selected this block, go directly to Section 6.

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	2	3				4			5
No Problem		A slight problem An obvious problem				A serious problem			A very serious problem

					Rating			Frequency of Problem

1.	Handling frustration appropriately		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
1.	Handling frustration appropriately

2.	Being patient when necessary		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
2.	Being patient when necessary

3.	Taking care of personal hygiene		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
3.	Taking care of personal hygiene

4.	Caring for physical needs		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
4.	Caring for physical needs		1	2	3	4	5
	(e.g., dressing, eating)

5.	Cooperating in, or being responsible for,		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
5.	Cooperating in, or being responsible for,		1	2	3	4	5
	taking needed medications

6.	Using good judgment regarding personal		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
6.	Using good judgment regarding personal		1	2	3	4	5
	safety and dangerous circumstances

7.	Identifying and appropriately asserting		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
7.	Identifying and appropriately asserting		1	2	3	4	5
	emotional needs

8.	Responding appropriately to changes in		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
8.	Responding appropriately to changes in		1	2	3	4	5
	own mood (e.g., calming self)

9.	Using appropriate coping skills to meet		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
9.	Using appropriate coping skills to meet		1	2	3	4	5
	daily demands of school environment

10.	Knowing when to ask for help		1	2	3	4	5	Monthly	Weekly	Daily	Hourly
10.	Knowing when to ask for help

Form SSA-5665-BK (06-2018) UF

Page 9 of 10

6. 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?

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)


Is medication prescribed for this child?		Yes	No	Don't Know	Specify below, if known.

Does this child take the medication on a regular basis?	Yes	No	Don't Know

Does this child's functioning change after taking medication?	Yes	No	Don't Know
If yes, please explain below

Does this child frequently miss school due to illness?

If yes, please explain below

Yes

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 (06-2018) UF	Page 10 of 10

7. 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:

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?	a.m.	p.m.

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?	a.m.	p.m.

Thank You

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1. First, when filling out the questionnaire for teachers, begin with the area that contains the subsequent blanks:

Completing section 1 in teacher questionnaire printable

2. Once your current task is complete, take the next step – fill out all of these fields - Actual Grade Level, Current Instructional Levels, Special Ed Services Frequency, Reading Level, StudentTeacher Ratio, Math Level, Written Language Level, Is there or was there an unusual, Yes, Dominant Language, English, Spanish, Other please specify, Any other names by which the, and IMPORTANT with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Is there or was there an unusual, Written Language Level, and English of teacher questionnaire printable

3. Completing Acquiring and Using Information, NO problems observed in this, YES the child has problems, Compared to the functioning of, RATING KEY FOR ACTIVITIES LISTED, No Problem, A slight problem, An obvious problem, A serious problem, A very serious problem, Comprehending oral instructions, Understanding school and content, Reading and comprehending written, Comprehending and doing math, and Rating is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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4. Your next subsection will require your input in the following areas: Understanding and participating in, Providing organized oral, Expressing ideas in written form, Learning new material, Recalling and applying previously, Applying problemsolving skills in, and What else can you tell us about. Ensure you enter all of the requested info to go further.

Filling in segment 4 of teacher questionnaire printable

Regarding Understanding and participating in and Learning new material, ensure that you review things in this section. These could be the most important fields in this form.

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