TN 7 (03-05)

A. Policy

The Teacher Questionnaire (TQ; SSA-5665-BK) and Request for Administrative Information (RAI; SSA-5666), originally designed to capture information about children claiming supplemental security income (SSI) under title XVI, are also useful for documenting the functioning of older individuals under both titles II and XVI when such individuals are, or have been, involved in an education or training program. When an individual age 18 or older (or an adolescent seeking disability for title II “child-in-care” purposes) is, or has recently been, in an education, vocational counseling, or training program, information provided in a TQ can be relevant to any assessment of his or her functioning under our rules, including determining whether:

• The individual has a severe impairment or combination of impairments;

• The individual’s impairment(s) meets or medically equals a listing that includes functional criteria, particularly the mental disorders listings;

• The individual has the ability to perform past or other work.

The policy and related procedures for the three forms required for developing evidence from the education community – the Authorization To Release Information to the Social Security Administration (SSA-827), the TQ, and the RAI – are in DI 25205.030.

B. Procedure - SSA-827, Authorization to Release Information to the Social Security Administration

1. Specific Authorization Required

1. The Family Educational Rights and Privacy Act (FERPA), the Individuals with Disabilities Education Act (IDEA), and the regulations of the Department of Education (DOEd) require specific authorization from an individual’s parent, caregiver, or guardian before a school can disclose information about the individual.

2. To satisfy this requirement, the DOEd helped SSA develop language specifically tailored to the education community. This language has been incorporated into the SSA-827 in the opening sections of the form that ask what records are to be released and from whom they are to be obtained.

2. Enter Claimant Identification Information

1. Name

2. SSN

3. Birth date (mm/dd/yy)

3. Signature Requirements

1. Individual authorizing disclosure

2. Witness to signature of person signing the form

C. Procedure - SSA-5665-BK, Teacher Questionnaire

1. SSA-5665-BK Is Required Form

1. The SSA-5665-BK, Teacher Questionnaire (TQ), is the only form approved by SSA and the Office of Management and Budget for requesting information from teachers about an individual’s functioning.

2. b. The TQ elicits teacher observations and assessments of an individual’s functioning in a broad range of activities compared to the functioning of same-aged individuals who do not have impairments.

2. Enter DDS Identification Information

1. DDS name

2. DDS address

3. Attach Label or Type Claimant’s Identification Information

1. Name

2. SSN

D. Procedure - SSA-5666, Request for Administrative Information

1. SSA-5666 Is Required Form

1. The SSA-5666, Request for Administrative Information, is the only form approved by SSA and the OMB for requesting records from all educational sources, e.g., schools, records administrators, counselors.

2. Such records comprise copies of educational tests or comprehensive evaluations, including Individualized Education Programs, triennial assessments, psychological or speech/language testing, teacher/therapist progress notes, and all such records that provide information about an individual’s functioning.

2. Provide DDS Identification Information

1. DDS name

2. DDS address

3. Attach Label or Type Claimant’s Identification Information

1. Name

2. SSN