TN 3 (03-05)

DI 25205.030 Teacher Questionnaire and Request for Administrative Information

A. Introduction

Information about an individual’s functioning in an education or training program may be critical to a determination of disability, whether the setting is a preschool, kindergarten, elementary or secondary school. Such information may also be important when a child is home-schooled. To ensure national uniformity and quality in the documentation process, SSA has created two forms for adjudicators at all levels to use in obtaining evidence from the education community.

1. Teacher Questionnaire (TQ) – SSA-5665-BK

a. Teacher Observations

The Teacher Questionnaire (TQ) asks for information directly from teachers or instructors based on their personal observations of an individual’s day-to-day functioning in the education setting, in both academic activities and social interactions. When assessing an individual’s limitations, teachers are asked to compare the person’s functioning to that of same-aged individuals who do not have impairment(s).

b. Structure of the TQ

The structure of the TQ is intended to facilitate both the teacher’s task of answering the questions, and the adjudicator’s task of using those responses when evaluating an individual’s impairment(s). Since it was originally created to serve the needs of the title XVI childhood disability program, the structure of the TQ parallels the domains of functioning used in the Childhood Disability Evaluation Form (SSA-538) and described in DI 25225.025 DI 25225.055. However, the TQ is sufficiently generic to be used in other kinds of cases (as discussed in Policy below).

2. Request for Administrative Information (RAI) – SSA-5666

The Request for Administrative Information (RAI) asks for information from administrative personnel that can be obtained from an individual’s existing education records; for example, from psychological and academic testing, speech-language therapy progress notes, comprehensive triennial evaluations, and Individualized Education Programs (IEPs). It also asks for copies of these and other such records that can help an adjudicator evaluate the person’s functioning.

B. Policy

1. When These Forms Are Used

a. Forms are used in title XVI childhood disability cases

The TQ and RAI are used primarily in title XVI SSI childhood disability cases when children (from around age 3 or 4 to attainment of age 18) attend any kind of school (nursery, pre-kindergarten, kindergarten, elementary, secondary), including home-school at any level.

b. Forms can be used in other disability cases

The TQ and RAI may also be useful in other cases when an individual alleging disability has recent or current involvement in an education or training program. Information from the education community or home-school situation may help to document the functioning of:

  • adolescents for whom disability is being sought under title II, for the purposes of parent or grandparent “child-in-care” benefits (see DI 23505.001 and DI 23505.005.);

  • young adults (age 18 or older) who are applying for benefits based on disability under title XVI or title II (see DI 22000.000);

  • young adults who are applying for Childhood Disability Benefits (CDB) as disabled adult children under title II (see DI 22505.011 concerning DDS development of CDB claims).

2. Why the TQ Can Apply to Individuals Older or Younger than “School-Age”

The TQ was designed primarily to capture teachers’ observations and assessments of school-age children, but it is also useful for documenting the functioning of individuals who are younger than age 6 or older than age 18 when such individuals are, or have been, involved in an education or training program. Not all the activities listed in the TQ are performed by individuals of all ages; e.g., at age 4, children are usually not readers. However, most of the questions and activities cited in the TQ are applicable to a broad range of ages (e.g., paying attention when spoken to directly, taking turns in a conversation, integrating sensory input with motor output), and may be asked across a variety of education and training settings.

3. TQ Provides Evidence for Any Step in the Title XVI Childhood or Title XVI Adult or Title II Sequential Evaluation Processes

a. Title XVI childhood disability

When a child is, or has recently been, in an education or training program, a completed TQ provides information about any problems he or she has across a very broad range of activities when compared to other same-aged children who do not have impairment(s). The TQ is useful, therefore, for evaluating a child’s impairment(s) throughout the title XVI childhood sequential evaluation process (see DI 25201.005). For example, for deciding whether:

  • A child has a severe impairment or combination of impairments; i.e., one that causes more than minimal functional limitations;

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

  • A child’s impairment(s) functionally equals the listings.

b. Title XVI adult disability or title II disability

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 (see DI 22001.001), including determining whether:

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

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

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

4. TQ Captures Critical Information about Functioning

a. Relevant to all impairments

The TQ can provide useful information about the effects of any impairment(s) (physical, mental, or combination of physical and mental) on a person’s ability to function, because it elicits responses about all aspects of functioning, regardless of the nature of the individual’s impairment(s).

b. Intensity of problem

A teacher’s responses on the TQ describe the severity, or intensity, of an individual’s problems with activities. The TQ severity rating key uses common sense terms (e.g., “a slight problem,” “a very serious problem”) that capture the same range of limitations that are evaluated in disability claims, i.e., from no impact on a person’s functioning to extreme impact.

c. Frequency of problem

For several categories of activities, the TQ also captures information about the frequency of any problem an individual may have in performing a particular activity, again, in common sense terms (e.g., “weekly,” “hourly”). Like the information about the intensity of an individual’s problem with an activity, this information about the frequency of a problem can also provide perspective on the effects of an impairment(s).

For example, a child who has “an obvious problem” on an hourly basis with “paying attention when spoken to directly,” “refocusing to task when necessary,” “carrying out single-step instructions,” and “changing from one activity to another without being disruptive,” may demonstrate a greater limitation in Attending and Completing Tasks than a child who has “a serious problem” on a monthly basis with “completing work accurately without careless mistakes,” and “working at a reasonable pace/finishing on time.”

This is important, because knowing the frequency of an individual’s problem, in combination with its intensity, as well as the number of affected activities, can help in making a judgment about the effects of an individual’s impairment on his or her functioning.

d. Quality and independence of functioning

  • The TQ supplements the questions about specific activities with more general questions about the quality and independence of an individual’s functioning. Functioning independently means doing age-appropriate activities in an age-appropriate manner, without needing help or supports that other children the same age typically do not need. See DI 25210.020.

  • Of course, even typically developing younger children need some help with age-appropriate activities. The question is: Does a child need any form of assistance or support (from a person, medication, treatment, device, or structured setting) that is above and beyond what a child the same age without impairment would need? The more extra help a child needs, the less independent the child is in functioning, which increases the weight of this factor in the rating of his or her limitations.

  • Moreover, a child may appear to function very well in a particular activity or set of activities, but if he or she requires extra help to do so, then the child is not functioning as independently as same-age children without impairments. This information contributes to the total profile of the child and is essential to any determination about disability.

e. Comparison of functioning

The TQ asks the informant, who is familiar with the individual, to compare the individual’s functioning to that of same-aged individuals who do not have impairments. By training and experience, most teachers are quite knowledgeable about the typical functioning of unimpaired individuals of the same age as the claimant.

5. TQ Ratings Do Not Translate Directly into SSA-538 Ratings

Because the rating scales on the TQ and on the SSA-538 look similar and use similar terminology, some users have thought that TQ ratings should translate directly into SSA-538 ratings. For several reasons, however, a teacher's numerical ratings on a TQ cannot be translated directly into severity ratings on the SSA-538, and care must be taken not to "add up" or otherwise mechanically apply a teacher's responses to the SSA-538.

a. Rating activity vs. rating domain

The TQ reflects a teacher's observations about the severity of problems with individual activities, while the SSA-538 reflects ratings for the severity of limitations in broad domains, not for each particular activity

b. Degree of limitation may vary across activities

An individual’s ability to function in education-related activities and in an education setting is likely to be variable; i.e., he or she will be more limited in some activities, but less limited, or not limited, in others. As a result, the teacher will likely provide different ratings of limitation for different activities within a related group of questions.

c. No formula exists for converting TQ ratings into domain ratings or residual functional capacity (RFC) assessment

There is no formula for converting the teacher’s different intensity and frequency ratings for multiple activities into a single domain rating, or into a rating of an adult’s RFC for various kinds of work. Moreover, a teacher’s narrative comments are extremely important, because they provide the adjudicator a tool for more clearly understanding the numerical rating of an individual’s limitations in functioning.

NOTE: Some single activities may be so critical that limitations in such an activity are sufficient to establish the level of limitation in a domain (or in an RFC category), even if other domain-related activities (or RFC categories) do not appear to be limited. See DI 25225.020B.1 and DI 25225.020C.1. Even when such critical activities are concerned, however, the teacher’s observations are not considered in isolation; see DI 25205.030D.6.

6. TQ Evidence Does Not Stand Alone

Like every kind of evidence, TQ information must be considered in the context of all available information about the individual. A completed TQ from a knowledgeable teacher provides exceptionally useful information about an individual’s day-to-day functioning, but that information must be evaluated in light of test scores, medical evidence, information from parents, etc.

7. Requesting Offices Cannot Substitute Their Own Forms for the TQ and RAI

Requesting Offices must use only the SSA-5665-BK and SSA-5666 to request information from schools and education programs. In addition, Requesting offices must not delete, modify, reword, reorganize, or change in any way the questions and explanations presented in either the SSA-5665-BK or the SSA-5666. Reqesting offices may, if necessary in a given case, ask additional questions related to the individual’s functioning; e.g., more detailed questions about the effects of the person’s particular impairment.

8. SSA-827 (Authorization To Release Information to the Social Security Administration) Must Accompany the TQ and RAI

All requests for information from the education community must be sent under the cover of an SSA-827, Authorization To Release Information to the Social Security Administration. This is because the Family Educational Rights and Privacy Act, the Individuals with Disabilities Education Act, and Department of Education regulations require that schools have specific authorization from a child’s parent, caregiver, or guardian before disclosing information about the individual to a third party. Specific language pertaining to requests sent to the education community was incorporated into the SSA-827 to satisfy these requirements.

9. Obtaining Information for Home-School Situations

a. Using the TQ for Home-Schooled Students

When a child of any age is home-schooled, adjudicators can use the TQ to obtain information about the child’s functioning in the education setting. Like educators in formal school systems, the home-school teacher much base all ratings on the TQ on his or her observations of the child as a student, and must compare the child’s functioning to that of children the same age who do not have impairments.

b. Using the RAI and SSA-827 To Obtain Student Records from Home-School Situations

Request a student’s records from the home-school teacher(s) with the RAI under the cover of an SSA-827. Although the RAI is intended for use by administrative and pupil personnel offices, adjudicators may use it in its present form to request records of the student’s education status and progress from the home-school teacher(s). Items 1 through 5 apply, along with item 6 concerning Therapies, and the section for Additional Comments.

c. Quantity and Quality of Home-School Records

State requirements regarding hoome-schooling vary broadly from no regulation at all (i.e., states do not require parents to notify the school system of the intent to home-school their children), to high regulation (i.e., states require parents to send notification or achievement test scores and/or professional evaluations, plus other documentation, e.g., curriculum approval by the state, teacher qualifications of parents, or home visits by state officials). Whether a home-school teacher has produced records of a child’s academic progress may, therefore, depend on the regulations of the state in which the child lives. If adequate records of a child’s academic status and daily functioning in the education setting are not available, an adjudicator may:

  • Try to identify sources in the child’s community who could provide helpful information about the child’s functioning (e.g., clergy, scout leader, neighbors);

  • Determine that a consulative examination is needed to obtain needed information about the child’s functioning.

C. Procedure – Requesting the TQ and RAI

1. Request Completion of the SSA-5665-BK and SSA-5666

Whenever a child or other individual alleging disability is involved in an education or training program, send an SSA-5665-BK to obtain the observations of teachers or instructors about the person’s day-to-day functioning in the education setting. Send an SSA-5666 to obtain information from, and copies of, the person’s education records.

  1. Do not delay sending the requests to schools and teachers while you are waiting to receive other evidence.

  2. Do not substitute any requesting office form for the TQ or RAI , and do not alter in any way the questions and explanations presented in these two forms.

  3. If necessary in a specific case, ask additional or more detailed questions related to the person’s functioning to obtain more detailed information about the effects of his or her impairment(s).

  4. If requested TQ/RAI are not received after every reasonable effort to obtain them, document the file regarding the non-receipt to show that the school or education facility did not provide the requested forms.

  5. Do not send requests for the TQ/RAI when:

    • The school or education program is known not to respond to your requests. (Document the file to explain why the TQ/RAI were not requested in the case.)

    • Sufficient evidence to support a fully favorable determination is already in file.

2. Send SSA-5665-BK and SSA-5666 Under Cover of Signed SSA-827

See DI 25205.030B.3.

3. Signatures Are No Longer Required on Either the TQ or the RAI

It is no longer necessary for the person completing the TQ or RAI to provide a signature on these forms. However, it is still necessary to obtain the name of the individual(s) completing the TQ or providing the information on the RAI.

D. Procedure – Using Information from the TQ and RAI

1. Use Details about Functioning To Help Create a Profile

Examine the teacher’s responses on the TQ about the individual’s functioning in school-related activities, along with information from the RAI , to help create a profile of the person’s limitations. Are the limitations impairment-related? That is, is it reasonable to conclude that the limitations result from the individual’s medically determinable impairment(s)

2. Consider Any Factors Related to Person’s Functioning

Incorporate into the individual’s profile all information from the TQ and RAI about factors that are relevant to the person’s functioning. See DI 25210.005ff. For example, a child may have a placement in a self-contained classroom with a low teacher/student ratio and adult aides that make possible a lot of one-to-one instruction and unusually close supervision. What does the