Form Ssa-5665-Bk - Teacher Questionnaire Page 3
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10Form Approved
OMB No. 0960-0646
SOCIAL SECURITY ADMINISTRATION
REQUESTING OFFICE NAME AND ADDRESS
ATTACH LABEL OR TYPE IN CLAIMANT NAME
TEACHER QUESTIONNAIRE
THIS FORM SHOULD BE COMPLETED BY THE PERSON(S) MOST FAMILIAR
WITH THE CHILD'S OVERALL FUNCTIONING.
Name of School:
1. How long have you known, or did you know, this child?
2. How often, and for how long, do you, or did you, see this child?
For what subjects:
3.
Actual Grade Level:
Current Instructional Levels
Special Ed. Services & Frequency
Reading Level:
Math Level:
Student/Teacher Ratio:
Written Language
Level:
4.
Is there, or was there, an unusual degree of absenteeism?
If yes, please explain:
No
Yes
5. Dominant Language:
Spanish
English
Other (please specify)
6. Any other names by which the child is known:
IMPORTANT
Please compare this child’s functioning to that of same-aged children
who do not have impairments.
If the child is receiving special education services, please be sure to
compare his or her functioning to that of same-aged, unimpaired children
who are in regular education.
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 1
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