View Information Collection Request (ICR) Package
Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0960-0646
ICR Reference No:
202008-0960-016
Status:
Active
Previous ICR Reference No:
201703-0960-017
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Teacher Questionnaire; Request for Administrative Information
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
07/20/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
12/09/2020
Terms of Clearance:
The agency made minor modifications to the supporting statement to clarify the description of the information collection and how it is submitted. The agency made a minor modification to the form to clarify when a respondent should leave a response blank.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
07/31/2026
36 Months From Approved
07/31/2023
Responses
337,725
0
404,564
Time Burden (Hours)
209,952
0
251,178
Cost Burden (Dollars)
0
0
0
Abstract:
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. Forms SSA-5665-BK and SSA-5666 are available electronically to school and training program administrators on SSA’s website. 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-BK 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. Respondents are teachers and other education personnel.
Authorizing Statute(s):
US Code:
42 USC 1382c
Name of Law: Social Security Act
US Code:
42 USC 1383b
Name of Law: Social Security Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
85 FR 63630
10/08/2020
30-day Notice:
Federal Register Citation:
Citation Date:
85 FR 79064
12/08/2020
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
SSA-5665-BK (Electronic)
SSA-5665-BK (Electronic)
Teacher Questionnaire
SSA-5666 (Electronic)
SSA-5666
Request for Administrative Information
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
337,725
404,564
0
0
-66,839
0
Annual Time Burden (Hours)
209,952
251,178
0
0
-41,226
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
When we last cleared this IC in 2017, the burden was 251,178 hours. However, we are currently reporting a burden of 209,952 hours. This change stems from a decrease in the number of responses from 404,564 to 337,725. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.
Annual Cost to Federal Government:
$4,199,840
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
12/09/2020
An official website of the United States government
The .gov means it's official.
The site is secure.
