Form Ssa-5665-Bk - Teacher Questionnaire
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10TEACHER 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 our 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
nonmedical 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 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. 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 (09-2011) ef (09-2011)
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