Teacher Questionnaire; Request for Administrative Information

When determining the effects of a child’s impairment(s), SSA obtains information about the child’s functioning from teachers, parents, and others who have the opportunity to observe the child on a daily basis. SSA uses Forms SSA-5665-BK and SSA-5666 to make one-time requests for teacher reports; results of formal testing; therapy progress notes; individualized education programs; and other records of a child’s educational aptitude and achievement. Forms SSA-5665-BK and SSA-5666 are available electronically to school and training program administrators on SSA’s website. State Disability Determination Services (DDS) or SSA may send a request for completion of the SSA-5665-BK to a child’s local school administrative office or training program, which refers the request to the child’s teacher(s), who then accesses the form through the link. The teacher(s) forwards the completed SSA-5665-BK to the school’s or training program’s administrative office, which uploads it to SSA’s Electronic Records Express (ERE) system. The DDS or SSA may send a request for completion of the SSA 5666 and copies of the child’s school records to the central or local administrative school office, depending on which office maintains the child’s individual academic records. The administrative office or training program can also upload the child’s records via ERE. Although the SSA-5665-BK and SSA 5666 are available for online completion, some teachers and school personnel may print and manually complete the forms, then fax or mail them to the requesting DDS or SSA office. Respondents are teachers and other education personnel.

The latest form for Teacher Questionnaire; Request for Administrative Information expires 2026-07-31 and can be found here.

SSA-5665-BK (Electronic)

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.