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- Click ‘Get Form’ to open the SSA 5666 in the editor.
- Begin by entering the claimant's name and the requesting office's name and address at the top of the form.
- In Section 1, indicate if there has been any recent evaluation or testing of the child. If yes, specify the type of test and date.
- Proceed to Section 2 to note if the child has been referred for assessment or special services, including relevant dates.
- Fill out Section 3 with current instructional levels in reading, math, and written language, including scores and assessment instruments used.
- In Section 4, check any grades that have been repeated by the child.
- Section 5 requires you to list any educational disabilities. Check all that apply and provide specifics where necessary.
- Complete Section 6 by checking applicable placement and related services, indicating hours per week as needed.
- Use the additional comments section for any further information that may assist in evaluating the child's functioning.
- Finally, provide your name, title, and contact information on the last page before submitting.
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REQUEST FOR ADMINISTRATIVE INFORMATION. Please ask the person(s) most familiar with the childs records to complete this form. Continue any answers as needed on
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FORM SSA-5666 (04-2018) UF SOCIAL SECURITY ADMINISTRATION Please ask the person(s) most familiar with the childs records to complete this form.