View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

SSA-5665-BK (Teachers)
 
No Modified
 
Voluntary
 
20 CFR 416.1103(f)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction SSA-5665-BK (Electronic) Yes Yes Fillable Fileable Signable
Other-Cover Letter No   Paper Only
Other-Cover Letter Yes Yes Fillable Printable
Other-Revised PA Statement Yes Yes Fillable Fileable Signable
Other-Revised PA Statement No   Paper Only

Income Security General Retirement and Disability

 

211,487 0
   
Individuals or Households
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 211,487 0 0 -35,052 0 246,539
Annual IC Time Burden (Hours) 246,735 0 0 82,376 0 164,359
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-5665-BK - Teacher Questionnaire -Current 07/01/2026
Disability Case Development- Paper Cover Letter Template-Current 07/28/2026
Disability Case Development Electronic Cover Letter -current 07/28/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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