Form Ssa-5666 - Request For Administrative Information
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2Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0646
ATTACH LABEL OR TYPE IN CLAIMANT NAME
REQUESTING OFFICE NAME AND ADDRESS
REQUEST FOR ADMINISTRATIVE INFORMATION
Please ask the person(s) most familiar with the child's records to complete this form.
Continue any answers as needed on next page.
Name of School
1.
Date(s):
Has there been any recent evaluation or testing of this child? If yes, kind(s) of
test / evaluation:
Please send us copies of all comprehensive evaluations, triennial assessments, psychological or speech/
language testing, current Individualized Education Programs, teacher/therapist progress reports, and all
other records that can help us evaluate the child's functioning.
2.
Has the child been referred for assessment team evaluation or special class placement or
Date(s):
services? If yes, to whom?
3. Current Instructional Levels Standardized Assessment Instrument
Score/Percentile Rank
Date(s):
Reading Level:
Math Level:
Written Language
Level:
4.
Grade(s) repeated, if any:
K
1
2
3
4
5
6
7
8
9
10
11
12
5.
Educational Disabilities, if any:
Other Health Impairment (please specify)
Intellectual Disability
Hearing Impairment/Deafness
Specific Learning Disability (please specify)
Speech or Language Impairment
Visual Impairment/Blindness
Emotional Disturbance/Behavior Disorder
Developmental Delay (please specify)
Orthopedic Impairment
Autism
Multiple Disabilities (please specify)
Traumatic Brain Injury
6.
Placement and Related Services (Check all that apply):
Regular Education, no special instruction
Therapies, etc:
Hours/week:
Hours/week:
Special Ed. Instruction:
Occupational Therapy
Inclusion - Sp. instr. in regular class
Physical Therapy
Resource Room
Speech - Language Therapy
Self-contained, regular school
Counselling (please specify)
Self-contained, special school
Special school, non-public
Other (please specify)
Residential
PLEASE PROVIDE YOUR NAME AND TITLE ON NEXT PAGE
Page 1
Form SSA-5666 (01-2016)
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