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Instructions for Completing the Teacher Questionnaire

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The Form SSA-5665 is an important element in the decision whether a child qualifies for disability benefits.  Please read all instructions and questions carefully and complete the form in its entirety.  The information you provide is key for the child being evaluated.
 

Answers For 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 questionnaire.

  1. WHY DO YOU NEED INFORMATION FROM ME?

  1. 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 eligibility may be related to his or her level of functioning at school, at home, or in the community. The information you provide about his or her day-to-day functioning in school will help us to determine the effects of the child's impairment(s) on his or her functioning. 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 the child has been (or was) in your class 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.

  1. IS THIS REQUEST REDUNDANT? THIS CHILD HAS ALREADY BEEN EVALUATED UNDER THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA).

  1. 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.

  1. I DO NOT THINK THE CHILD IS DISABLED.  SHOULD I COMPLETE THIS FORM?

  1. 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.

  1. THE FORM IS LONG. DO I NEED TO ANSWER EVERY QUESTION?

  1. 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. It is also organized 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 skip to the next section.

We appreciate your cooperation, your time, and your effort in completing the questionnaire.

Helpful Hints For Completing The Form

The following are some helpful tips on completing the Word version of the Teacher Questionnaire:

  • The body of the form is locked. We recommend first saving a blank copy (File + Save As) to your local drive prior to completion. 

  • If you receive frequent requests from the same source(s), you may want to pre-fill the DDS name, Address, School name, teacher’s name, and phone number (pages 1 & 8).  Leave the rest of the form blank and then save it as a master template.

  • When navigating through the form, avoid using the "Enter" (hard return) key.  Pressing "Enter", when inserting data and/or moving throughout the form, can create formatting errors.  You should use the "Tab" key, the directional arrows, or your mouse (plus click), to move the cursor from one text field to the next.   To begin a new line, simultaneously press the Shift and Enter.

  Graphic of the top half of the form's 1st page that indicates you should press Shift + Enter to begin a new line of text
 
 

  • Carefully read the instructions at the beginning of each section.  If a specific assessment category does not apply to the child you are assessing, the instructions advise you to skip (go directly) to the next section.

  • If you need to change a rating entry, click on the box already checked to erase the selection and then click on the new rating box.  (See illustration below).

  

 

 Graphic that shows that, if you need to change an entry, you should click on the box you already checked to erase the selection before you choose a new rating box.
 
 

  • When entering text in a comment box, the text will automatically wrap to the next line, if it extends beyond the margin.

  
  Graphic that indicates that, when you enter text in a comment box and it extends beyond the margin, the text will automatically wrap to the next line

When The Form Is Completed

  • Print and fax the form to the number on the DDS request letter (use your personal computer's fax feature if available) using the barcode page as the first page, OR

  • Forward the file in a secure e-mail to your school or district records administrator if they are registered to use SSA's secure Electronic Records Express website.

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Last reviewed or modified Wednesday Nov 05, 2008
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