Form SSA-5665-BK (01-2024) 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 enclosed 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 (01-2024) UF Page 2 of 10
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 221, 223, 1614(a), 1631(e), and 1633 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 an accurate and timely decision on the named claimant's eligibility for benefits
claim filed.

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

• 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 Social Security Act; and
• To Federal, State, or local agencies (or agents on their behalf), for administering income or health
maintenance programs including programs under the Social Security Act.

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 Notices (SORN) 60-0089,
Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422;
and 60-0320, Electronic Disability (eDIB) Claim File, as published in the FR on June 4, 2020, at 85 FR
34477. Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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 (01-2024) 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:
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:
Math Level:
Student/Teacher Ratio:
Written Language
Level:
4. Is there, or was there, an unusual degree of absenteeism? Yes No If yes, please explain:

5. Dominant Language: English Spanish 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 (01-2024) 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 observed activity listed below. If you have not observed a specific activity,
please leave that activity blank.
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 2 3 4 5
1. Comprehending oral instructions
1 2 3 4 5
2. Understanding school and content vocabulary
1 2 3 4 5
3. Reading and comprehending written material
1 2 3 4 5
4. Comprehending and doing math problems
1 2 3 4 5
5. Understanding and participating in class discussions
1 2 3 4 5
6. Providing organized oral explanations and adequate descriptions
1 2 3 4 5
7. Expressing ideas in written form
1 2 3 4 5
8. Learning new material
1 2 3 4 5
9. Recalling and applying previously learned material
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 (01-2024) 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 observed activity listed below. If you have not observed a specific activity,
please leave that activity blank.
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
Monthly Weekly Daily Hourly
1. Paying attention when 1 2 3 4 5
spoken to directly
Monthly Weekly Daily Hourly
2. Sustaining attention during 1 2 3 4 5
play/sports activities
Monthly Weekly Daily Hourly
3. Focusing long enough to 1 2 3 4 5
finish assigned activity or task
Monthly Weekly Daily Hourly
4. Refocusing to task 1 2 3 4 5
when necessary
Monthly Weekly Daily Hourly
5. Carrying out 1 2 3 4 5
single-step instructions
Monthly Weekly Daily Hourly
6. Carrying out 1 2 3 4 5
multi-step instructions
1 2 3 4 5 Monthly Weekly Daily Hourly
7. Waiting to take turns

Monthly Weekly Daily Hourly

8. Changing from one activity to 1 2 3 4 5
another without being disruptive
Monthly Weekly Daily Hourly
9. Organizing own things 1 2 3 4 5
or school materials
Monthly Weekly Daily Hourly
10. Completing class/ 1 2 3 4 5
homework assignments
Completing work accurately 1 2 3 4 5 Monthly Weekly Daily Hourly
11. without careless mistakes

Monthly Weekly Daily Hourly

12. Working without distracting 1 2 3 4 5
self or others
Monthly Weekly Daily Hourly
13. Working at reasonable pace/ 1 2 3 4 5
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 (01-2024) 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 observed activity listed below. If you have not observed a specific activity,
please leave that activity blank.
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
Monthly Weekly Daily Hourly
1. Playing cooperatively 1 2 3 4 5
with other children
1 2 3 4 5 Monthly Weekly Daily Hourly
2. Making and keeping friends

1 2 3 4 5 Monthly Weekly Daily Hourly

3. Seeking attention appropriately

1 2 3 4 5 Monthly Weekly Daily Hourly

4. Expressing anger appropriately

Asking permission 1 2 3 4 5 Monthly Weekly Daily Hourly

5. appropriately

Monthly Weekly Daily Hourly

6. Following rules 1 2 3 4 5
(classroom, games, sports)
Monthly Weekly Daily Hourly
7. Respecting/obeying adults 1 2 3 4 5
in authority
Monthly Weekly Daily Hourly
8. Relating experiences 1 2 3 4 5
and telling stories
Monthly Weekly Daily Hourly
9. Using language appropriate 1 2 3 4 5
to the situation and listener
Monthly Weekly Daily Hourly
10. Introducing and maintaining relevant 1 2 3 4 5
and appropriate topics of conversation
1 2 3 4 5 Monthly Weekly Daily Hourly
11. Taking turns in conversation

Monthly Weekly Daily Hourly

12. Interpreting meaning of facial expression, 1 2 3 4 5
body language, hints, sarcasm
Using adequate vocabulary and grammar
13. to express thoughts/ideas in general, 1 2 3 4 5 Monthly Weekly Daily Hourly
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 (01-2024) UF Page 7 of 10
3. Interacting and Relating with Others (Continued)
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.)

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
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?
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 observed activity listed below. If you have not observed a specific activity,
please leave that activity blank.
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
weight, bending, kneeling, crouching, walking, running, jumping, climbing)

2. Moving and manipulating things (e.g., pushing, pulling, lifting, carrying, 1 2 3 4 5

transferring objects; coordinating eyes and hands to manipulate small objects)

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

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

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

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

7. Planning, remembering, executing controlled motor movements 1 2 3 4 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.)
Form SSA-5665-BK (01-2024) 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 observed activity listed below. If you have not observed a specific activity,
please leave that activity blank.
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 2 3 4 5 Monthly Weekly Daily Hourly
1. Handling frustration appropriately

1 2 3 4 5 Monthly Weekly Daily Hourly

2. Being patient when necessary

1 2 3 4 5 Monthly Weekly Daily Hourly

3. Taking care of personal hygiene

1 2 3 4 5 Monthly Weekly Daily Hourly

4. Caring for physical needs
(e.g., dressing, eating)
1 2 3 4 5 Monthly Weekly Daily Hourly
5. Cooperating in, or being responsible for,
taking needed medications
1 2 3 4 5 Monthly Weekly Daily Hourly
6. Using good judgment regarding personal
safety and dangerous circumstances
1 2 3 4 5 Monthly Weekly Daily Hourly
7. Identifying and appropriately asserting
emotional needs
1 2 3 4 5 Monthly Weekly Daily Hourly
8. Responding appropriately to changes in
own mood (e.g., calming self)
1 2 3 4 5 Monthly Weekly Daily Hourly
9. Using appropriate coping skills to meet
daily demands of school environment
1 2 3 4 5 Monthly Weekly Daily Hourly
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? If so,
what kind and how often? (Continue on the last page if needed.)
Form SSA-5665-BK (01-2024) UF Page 9 of 10
6. 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? Yes No Don't Know Specify below, if known.

4. Does this child take the medication on a regular basis? Yes No Don't Know
5. Does this child's functioning change after taking medication? Yes No Don't Know
If yes, please explain below

6. Does this child frequently miss school due to illness? Yes 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 (01-2024) 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