SSA-5665

Teacher Questionnaire

Download and Print the SSA-5665

Request may not be processed if the form is incomplete or illegible.

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.
Form SSA-5665-BK (09-2011) ef (09-2011)

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

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

Q. IS THIS REQUEST REDUNDANT? WE (OR OTHERS) HAVE ALREADY EVALUATED THIS CHILD UNDER THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA).

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