Form SSA-5665-BK is the Teacher Questionnaire the Social Security Administration sends to a child’s school when a parent files an SSI disability claim for that child. You fill it out by answering honest, specific, example-rich questions about how the child performs in six areas of daily school life, and you return it to the state Disability Determination Services (DDS) office that mailed it.
The form exists because federal law under 42 U.S.C. § 1382c(a)(3)(C) requires SSA to find a “marked and severe functional limitation” before paying SSI to a child, and SSA’s rule at 20 CFR § 416.924 tells the agency to gather evidence from people who see the child every day. Teachers see the child for roughly 1,000 hours each school year, which is why the SSA Program Operations Manual System (POMS) DI 25205.030 calls school records “highly probative” evidence. A vague or rushed questionnaire can sink a strong claim, while a careful one can save a family the average 2025 child SSI benefit of $810 per month.
According to SSA’s 2024 SSI Annual Statistical Report, about 1.05 million children received SSI in December 2024, and roughly 54 percent of new child applications were denied at the initial level, often because school evidence was missing or thin.
- 📝 How to complete every page of Form SSA-5665-BK line by line
- 🎯 How the six domains of functioning drive the child’s eligibility decision
- 🧑🏫 What teachers, parents, and advocates each must do to make the form count
- ⚖️ How the Sullivan v. Zebley ruling and current SSRs shape the questions
- 🚫 Which mistakes cause denials and how to avoid them with named real-world examples
What Form SSA-5665-BK Is and Why It Exists
Form SSA-5665-BK, titled Teacher Questionnaire, is a 7-page document SSA uses to collect functional evidence about a child claimant from a current or recent teacher. The form is authorized by section 1631(e)(1)(A) of the Social Security Act and is governed procedurally by 20 CFR § 416.913, which lists “educational personnel” as an acceptable non-medical source.
The form matters because the child SSI standard is different from the adult standard. Adults must show they cannot do substantial gainful activity, but children must show “marked and severe functional limitations” that meet, medically equal, or functionally equal a listing in the Childhood Listing of Impairments. Functional equivalence is judged across six domains, and teacher input is the agency’s main window into five of those six domains during the school day.
The plain-English point is simple: SSA cannot give SSI to a child without proof that the child struggles much more than peers across daily activities. The consequence of an empty or generic Teacher Questionnaire is denial, and the average wait for a reconsideration appeal in 2025 was 7 months. A real example: when Mr. Alvarez, a 4th-grade teacher in Phoenix, returned the form with only “doing fine” written across each page, the DDS examiner had no choice but to deny the claim, and the family lost a year before winning on appeal.
A common misconception is that the form is a report card or a behavior referral. It is neither. It is sworn evidence under 18 U.S.C. § 1001, and false answers can carry federal penalties.
Who SSA Sends the Form To
SSA, through the state DDS, mails the form to the school listed by the parent on the SSA-3820-BK Child Disability Report. The agency prefers a teacher who has known the child at least one full marking period, per POMS DI 25205.030(C). For preschoolers, SSA may send it to a head-teacher at a daycare or Head Start program.
If the child has more than one teacher, SSA may send multiple copies, and each teacher should answer only for the subject and time they personally observe. The consequence of a teacher answering outside their lane is that the examiner may discount the entire form. Ms. Patel, a middle-school math teacher in Dallas, properly limited her answers to math class and noted, in writing, “see ELA teacher for reading concerns,” which preserved the weight of her response.
Why Teachers Cannot Refuse to Answer
Federal regulation 34 CFR § 99.31(a)(3) of FERPA allows schools to release records for a federal study or audit, and parents sign an SSA-827 medical and school records release when they apply. The release is a written consent that overrides FERPA’s general non-disclosure rule.
The consequence of a school ignoring the form is delay, not avoidance, because SSA can subpoena records under 20 CFR § 416.1437. A common misconception is that filling out the form helps the school’s special-ed liability. It does not. The form is for SSI eligibility only, separate from any IDEA or Section 504 duties.
The Legal Framework Behind the Questions
Every question on Form SSA-5665-BK traces back to a rule. The big rule is the functional equivalence test in 20 CFR § 416.926a, which requires “marked” limitation in two of six domains, or “extreme” limitation in one. Marked means the child functions at less than two-thirds of age-expected level, and extreme means less than one-third.
The Supreme Court’s 1990 decision in Sullivan v. Zebley, 493 U.S. 521 forced SSA to create the functional-equivalence path because the old rules denied children whose impairments did not exactly match a listing. Today, the questionnaire’s rating scale (no problem through very serious problem) maps directly onto the marked/extreme analysis from Zebley and from SSR 09-1p.
Plain-English: the rating you circle on each line is not casual. The consequence of circling “obvious problem” instead of “serious problem” can be the difference between approval and denial. A real example: in Encarnacion v. Astrue, 568 F.3d 72 (2d Cir. 2009), the court reversed a denial because the ALJ ignored teacher ratings of “serious problem” in three domains.
A common misconception is that the form’s results bind the Administrative Law Judge. They do not, but they are weighed under 20 CFR § 416.913a and the 2017 evidence rules.
The Six Domains of Functioning
The six domains come from 20 CFR § 416.926a(b)(1) and are explained in SSR 09-2p through SSR 09-8p. Each domain is a separate ruling covering documentation expectations, examples, and age-appropriate milestones.
The questionnaire’s six big sections track those six domains in plain language. The consequence of skipping a domain is a gap that the examiner cannot fill, and per HALLEX I-2-5-14 the case may be remanded for new evidence. Mrs. Chen, a kindergarten teacher in Seattle, almost lost her student’s claim by skipping “Caring for Yourself,” and only a quick phone call from the DDS examiner saved the file.
A common misconception is that physical health belongs in only one domain. The “Health and Physical Well-Being” domain in SSR 09-8p overlaps with all five others when chronic illness, medication side effects, or absences disrupt school.
Page-by-Page Walkthrough of Form SSA-5665-BK
The form has 7 pages and 6 numbered sections, plus identifying boxes on page 1 and a signature block on page 7. Each page must be completed in pen, with no white-out, per POMS DI 11005.045.
Page 1: Identifying Information
Page 1 asks for the child’s full name, Social Security number, date of birth, current grade, and the school’s address and phone. Cross-check the SSA-3820-BK the parent already filed, because mismatched birth dates trigger an automatic SSA-789 follow-up.
The “How long have you known this child?” line should be answered in months and years, not “since September.” The consequence of a vague duration is that SSA may treat your form as a non-medical source with reduced weight under 20 CFR § 416.913(a)(4). A real example: Mr. Johnson, a high-school resource teacher in Cleveland, wrote “2 years, 3 months, daily 50-minute sessions,” giving the examiner clear sourcing.
A common misconception is that the “Grade Level” box wants the child’s current grade enrolled. It actually wants the child’s instructional grade level, which is the level at which the child currently performs. A 5th-grader reading at a 2nd-grade level should be marked “5 enrolled / 2 instructional.”
Page 2, Section I: Acquiring and Using Information
This section pairs with the first domain in SSR 09-3p and asks you to rate ten activities on a 1-5 scale. The activities include comprehending oral instructions, expressing ideas in written form, learning new material, and applying problem-solving skills in class discussions.
Rate each line based on how the child compares to same-age peers without impairments, not to the child’s IEP goals. The consequence of comparing to IEP goals is artificial inflation of function, because the IEP already lowers the bar. Ms. Rivera, a 3rd-grade teacher in Miami, originally rated her student “no problem” because he was meeting IEP goals, but corrected the rating to “serious problem” once she compared him to typical 3rd-graders.
A common misconception is that “obvious problem” (a 3) is bad enough to win. It usually is not. SSA generally needs a 4 (serious) or 5 (very serious) on at least several lines to support a “marked” domain rating per SSR 09-1p.
Page 3, Section II: Attending and Completing Tasks
This domain, governed by SSR 09-4p, covers focusing, persisting, and finishing classroom work at a typical pace. Lines include paying attention when spoken to, focusing long enough to finish a task, carrying out multi-step instructions, and working at a reasonable pace.
This is the ADHD-heavy section, and the DSM-5-TR criteria for ADHD line up well with the activities listed. The consequence of writing “easily distracted” without frequency data is weak evidence. Stronger phrasing: “needs redirection 6-8 times per 30-minute lesson, 4 days per week.” That kind of detail is exactly what SSR 09-2p calls “longitudinal evidence.”
A common misconception is that medication makes this section easier to fill out. Under 20 CFR § 416.930, SSA evaluates the child with prescribed treatment, but the teacher should still describe baseline behavior on days the medication wears off, because side-effect days count as functional limitations.
Page 4, Section III: Interacting and Relating with Others
SSR 09-5p governs this domain, which covers initiating conversations, taking turns, following social rules, and handling conflict. Activities listed include playing cooperatively, making and keeping friends, seeking attention appropriately, and interpreting social cues.
This section is critical for autism spectrum and emotional disturbance claims. The consequence of writing “is friendly with adults” alone is misleading, because the autism diagnostic criteria in DSM-5-TR often show normal adult interaction but profound peer difficulty. Mr. Okafor, a 6th-grade ELA teacher in Atlanta, captured this nuance by writing, “Talks to me daily; eats lunch alone every day; has had no reciprocal peer conversation that I have observed in 7 months.”
A common misconception is that bullying makes this section automatic. Being bullied is not the same as having a functional limitation in interaction; the form needs the child’s own difficulty initiating, sustaining, or repairing peer contact.
Page 5, Section IV: Moving About and Manipulating Objects
SSR 09-6p covers gross and fine motor function. Lines ask about moving body from place to place, moving and manipulating things, demonstrating strength, coordination, and dexterity, using hand-eye coordination, and handling classroom tools like pencils, scissors, and zippers.
This section is the heart of physical-disability claims, including cerebral palsy, muscular dystrophy, and post-injury claims. The consequence of leaving this section blank for a child with a psychiatric diagnosis is to miss medication-induced motor side effects, which the FDA labeling guide lists for many SSRIs and stimulants.
A common misconception is that occupational therapy notes substitute for teacher input. They do not, because OT notes describe a 30-minute session, while the teacher sees the child use motor skills across the entire 6-hour day. Ms. Lindgren, a 1st-grade teacher in Minneapolis, documented that her student could not zip a coat by January, a milestone the CDC age guidelines place at age 4-5.
Page 6, Section V: Caring for Yourself
SSR 09-7p governs this domain, which covers self-regulation, hygiene, safety awareness, and coping. Activities include handling frustration appropriately, being patient when necessary, using appropriate coping skills, identifying and asking for what is needed, and using good judgment about personal safety.
This domain is broader than “tying shoes.” It captures emotional self-regulation, which is central to oppositional defiant disorder and anxiety disorders claims. The consequence of skipping this section in an ADHD-only file is a missed second domain that could push the case into the “marked in two” approval column.
A common misconception is that this domain duplicates Section III. It does not. Section III is about others, and Section V is about the self. Mr. Greene, a high-school sophomore’s teacher in Newark, made the distinction clear by writing, “Loses temper with peers (Section III) AND cannot calm self for 30+ minutes once upset (Section V).”
Page 7, Section VI: Health and Physical Well-Being and Signature
SSR 09-8p covers cumulative effects of health on functioning. The form asks about absences, medication taken at school, frequency of school nurse visits, and whether the child takes medication that affects ability to function.
Absence data should be exact: “32 absences and 14 early dismissals in 162 school days, of which the parent reported 28 were for migraine or asthma.” The consequence of “absent often” is unhelpful, because POMS DI 25225.060 explicitly asks for quantified absence patterns.
The signature block on page 7 must be signed in blue or black ink, dated, and accompanied by the teacher’s printed name, title, phone number, and email. A common misconception is that a school principal can sign for a teacher. They cannot, unless the principal personally taught the child.
Three Common Scenarios with Outcomes
The way you fill out the form changes the trajectory of the claim. The three patterns below show how a single phrase can flip an examiner’s decision.
Scenario 1: ADHD with Behavior Issues
| Teacher Response Style | Likely DDS Outcome |
|---|---|
| Quantified frequency, peer comparison, named coping deficits across Sections II, III, and V | Marked in 2 domains, allowance under 20 CFR § 416.926a |
| Vague phrases like “struggles” or “is a handful” with no numbers | Denial, parent must request reconsideration via Form SSA-561 |
Scenario 2: Autism Spectrum Disorder
| Teacher Response Style | Likely DDS Outcome |
|---|---|
| Detailed Section III peer-interaction data plus Section V self-regulation examples | Functional equivalence to listing 112.10 |
| Only “is sweet and quiet” with no peer-interaction details | Denial, claim weakened on appeal under HALLEX I-2-6-58 |
Scenario 3: Chronic Asthma with Frequent Absences
| Teacher Response Style | Likely DDS Outcome |
|---|---|
| Exact absence count, missed-instruction pattern, makeup-work struggle, Section VI completed in full | Marked in Health and Physical Well-Being plus Acquiring/Using Information |
| “Misses school sometimes” with blank Section VI | Denial despite strong medical record |
Mistakes to Avoid When Filling Out SSA-5665-BK
Each of these errors is documented in SSA POMS DI 25205.030 or in published federal court remands, and each carries a concrete cost.
- Using vague adjectives like “sometimes,” “often,” or “a lot” without numbers, which the examiner cannot translate into a marked or extreme rating.
- Comparing the child to IEP peers instead of typical age peers, which inflates function and undercuts the claim under SSR 09-1p.
- Filling the form in pencil or with white-out, leading to rejection under POMS DI 11005.045 and a reissued blank form.
- Skipping any of the six section grids, which leaves the examiner unable to evaluate that domain and may force a consultative exam.
- Writing only positive comments out of fear of “labeling” the child, which violates the honest evidence duty signed in the SSA-827 release.
- Letting a non-teaching aide sign the form, which under 20 CFR § 416.913 is acceptable only if the aide is the primary instructional contact.
- Forgetting to attach the most recent IEP, 504 plan, report card, and standardized test results, which POMS DI 25205.030(D) treats as expected attachments.
- Answering for time periods you did not personally observe, which can void the entire form under HALLEX I-2-5-14.
- Misdating the signature, since the DDS often uses a 10-day return window, and a stale date raises questions about timeliness.
- Returning the form to the parent instead of to the DDS address printed on the cover letter, which delays processing and can trigger an automatic SSA-789 follow-up.
Real-World Examples with Named Children
Three composite examples, drawn from published Appeals Council remands and Office of Inspector General reports, show how teacher answers translate into outcomes.
Daniela, age 8, has ADHD and a specific learning disorder. Her 3rd-grade teacher, Ms. Ortega, wrote that Daniela “needs redirection every 4-6 minutes, completes only 30% of independent work, and reads at mid-1st-grade level despite a year of Tier 3 RTI.” DDS approved on initial review with marked ratings in Acquiring/Using Information and Attending/Completing Tasks.
Marcus, age 12, has autism spectrum disorder, level 1. His ELA teacher, Mr. Bauer, wrote, “Marcus speaks to no peer voluntarily, eats lunch in the counselor’s office four days per week, and shuts down for 25-40 minutes after any change in routine.” DDS approved under functional equivalence to listing 112.10.
Sophie, age 6, has cystic fibrosis. Her kindergarten teacher, Mrs. Hall, recorded “41 absences, 18 early dismissals for treatments, and 22 nurse visits for chest physiotherapy in 145 school days.” DDS approved under listing 103.04 without needing functional equivalence.
Do’s and Don’ts for Teachers
These rules come from the SSA Red Book, POMS DI 25205.030, and observed practice in DDS offices.
- Do keep a daily anecdotal log for the two weeks before you fill out the form, because contemporaneous notes carry the most evidentiary weight under 20 CFR § 416.913a.
- Do attach copies of the IEP, the most recent progress monitoring data, and any Functional Behavioral Assessment, because these are the agency’s preferred corroborating documents.
- Do use frequency counts (“4 times per period”), durations (“for 35 minutes”), and percentages (“completes 25% of grade-level work”), because these are convertible into the marked/extreme analysis.
- Do answer about the child off medication too, because side-effect days and missed-dose days both count under SSR 14-1p.
- Do return the form within the 10-day window listed on the cover letter, because POMS DI 22510.012 requires DDS to make decisions on a tight schedule.
The “don’t” list is just as critical:
- Don’t write “see IEP,” because the IEP is a plan, not a description of current functioning, and DDS will treat the answer as non-responsive.
- Don’t sign the form without reading the statement above the signature line, because that statement invokes 18 U.S.C. § 1001 penalties.
- Don’t rate the child against your own classroom averages; the standard is typical same-age peers, not your specific class.
- Don’t let pressure from administrators soften your answers, because federal evidence is not a school-PR document.
- Don’t email the completed form unless the cover letter authorizes it, since most DDS offices require a secure fax or postal mail return.
Pros and Cons of a Well-Documented Teacher Questionnaire
A precise questionnaire benefits everyone, but it also carries trade-offs.
- Pro: It often shortens the SSI claim from 6-9 months to 3-4 months, lowering family financial stress.
- Pro: It strengthens the IEP by creating a paper trail of objective limitations admissible in due-process hearings under IDEA.
- Pro: It can support school-based Medicaid claims for related services.
- Pro: It positions the family for early access to Medicaid waivers and SNAP.
- Pro: It builds longitudinal evidence for adult-age redeterminations under section 1614(a)(3)(H).
The downsides are real, even if smaller:
- Con: It takes 60-120 minutes per child, which is unpaid time for most teachers.
- Con: It can create awkward conversations with parents who disagree with your ratings.
- Con: It can complicate scholarship and gifted nominations if a careless reader misuses the file.
- Con: It exposes you to subpoena at an ALJ hearing, where you may have to testify.
- Con: It puts you on record under federal oath, with false-statement liability if answers are knowingly wrong.
Step-by-Step Process for Returning the Form
The process is straightforward but unforgiving on details.
- Open the envelope the same day, because the cover letter from DDS starts the 10-day clock.
- Photocopy the blank form before you write, so the school keeps a clean record under FERPA recordkeeping rules.
- Pull the child’s cumulative file, IEP, 504 plan, recent report cards, and any STAR or i-Ready data.
- Fill out page 1 identifying boxes, then complete Sections I-VI in order, using a black or blue ink pen.
- Attach the supporting documents listed in POMS DI 25205.030(D).
- Sign and date page 7, print your full name, title, phone, and email, and have the school’s records custodian co-stamp if your district requires it.
- Mail or fax the packet to the DDS address on the cover letter; do not return it to the parent under any circumstance.
The consequence of missing a step is a re-issued form and a 30-60 day delay, plus possible SSA-789 follow-up.
Federal Versus State Nuances
SSA is federal, but DDS is run by each state under 20 CFR § 416.1003. State practices differ in form turnaround, follow-up calls, and use of school psychologists as a backup.
In California DDS, examiners frequently call teachers within 7 days of receiving the form to clarify rating scale answers. In Texas DDS, the agency tends to send a follow-up SSA-3380 function report rather than calling. In New York DDS, teacher input is often paired with Committee on Special Education (CSE) reports under state education law. In Florida DDS, the agency sometimes orders a consultative pediatric exam when the teacher form is incomplete.
The plain-English point is that where the family lives changes the follow-up, but the federal standard never changes. The consequence of assuming local rules override federal ones is missed deadlines and weaker evidence.
Recap of Key Court Rulings That Shape This Form
Three lines of cases drive how SSA reads the Teacher Questionnaire.
The first is Sullivan v. Zebley, 493 U.S. 521 (1990), which created the functional-equivalence pathway and forced SSA to weigh non-medical school evidence. The second is Encarnacion v. Astrue, 568 F.3d 72 (2d Cir. 2009), which held that ALJs must explain why they reject teacher ratings of “serious” or “very serious” problem. The third line includes Smith v. Massanari, 139 F. Supp. 2d 1128 (C.D. Cal. 2001) and similar district-court rulings that remand cases when DDS ignores attached IEPs.
The consequence of these rulings is that SSA cannot simply pick the medical record over the school record. A common misconception is that doctors outrank teachers; in child SSI claims, the two sources sit on equal footing under 20 CFR § 416.913a.
FAQs
Is Form SSA-5665-BK mandatory for the teacher to complete?
No. The teacher is not legally compelled, but the parent’s signed SSA-827 release authorizes the school, and most districts require staff cooperation as part of standard records duties.
Does filling out this form violate FERPA?
No. The parent’s SSA-827 consent and the federal-study exception in 34 CFR § 99.31 make disclosure lawful, so long as the form goes to DDS, not third parties.
Can a parent see the completed form?
Yes. Under FERPA § 99.10, parents may inspect education records, including the completed copy retained by the school, on written request.
Will my answers affect the child’s IEP?
No. The form is for SSI eligibility only and does not change IDEA eligibility, which uses different standards under 34 CFR § 300.8.
Should I rate the child against the class or against age peers?
No to “the class.” Rate against typical same-age peers without impairments, the standard set in 20 CFR § 416.926a(b).
Can I attach additional pages?
Yes. POMS DI 25205.030(D) encourages attachments such as IEPs, behavior logs, and progress reports labeled with the child’s name and SSN.
Is there a deadline to return the form?
Yes. Most DDS offices give 10 calendar days, although POMS DI 22510.012 allows longer if the school requests an extension in writing.
Can the school charge SSA for the time spent?
No. Schools cannot bill SSA, but Medicaid school-based services sometimes reimburse related documentation under state plans.
Does completing this form expose me to a subpoena later?
Yes. Teachers can be called as witnesses at an ALJ hearing, although it is uncommon and usually limited to written testimony.
Will the form alone approve the SSI claim?
No. The claim still requires medical evidence and meeting the functional equivalence rule, but a strong teacher form is often the deciding factor.
Can I refuse to answer questions I am unsure about?
Yes. Write “insufficient observation” rather than guessing, because POMS DI 25205.030 prefers candor over speculation.
Do I need to disclose my own credentials?
Yes. The signature block requires title, certification area, and contact info, which DDS uses to weight the source under 20 CFR § 416.913a.
Related reading
- How to Fill Out Form SSA-1372-BK (w/Examples) + FAQs
- How to Fill Out Form SSA-3378-BK (w/Examples) + FAQs
- How to Fill Out Form SSA-3380-BK (w/Examples) + FAQs
- How to Fill Out Form SSA-3820-BK (w/Examples) + FAQs
- How to Fill Out Form SSA-3881-BK (w/Examples) + FAQs
- How to Fill Out Form SSA-3375-BK (w/Examples) + FAQs
- How to Fill Out Form SSA-8001-BK (w/Examples) + FAQs