Information for Teachers and School Officials

About Students Who Apply For Disability Benefits

Social Security uses information from both medical and non-medical sources to decide whether a child qualifies for disability benefits.

• 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 non-medical sources who are familiar with the child is important, because a child's eligibility may be directly related to how well he or she functions at school, at home, or in the community.

When you complete the Teacher Questionnaire (SSA-5665), the information you provide about the way the child functions in school on a day-to-day basis will help us:

• determine the effects of the child's impairment(s) on his or her day-to-day activities.
• compare this child's ability to function with other children the same age who have no impairments.

We need this information from you even if the child has been (or was) in your class for only a short time.

Your response is not the only information we will consider when we decide if the child qualifies for disability benefits, but it is very important to us. Your information will help us make our decision.

• Instructions for Completing the Teacher Questionnaire [rich text format (.rtf)] [Word] [pdf]

• Teacher Questionnaire (SSA-5665). You can:

  • Fill out the [.rtf] or [Word] version of the questionnaire and print or save the completed questionaire.
  • Print the blank [pdf version] of the questionnaire and mail or fax the completed questionaire.