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SSI Questionnaires


Head Start/Early Head Start staff will comply with the Social Security Administration Request for Administration Information records form.


The Disabilities/Intervention Specialist, after reviewing the documentation will:

  1. Answer the questionnaire when appropriate and/or
  2. Share with other appropriate Head Start staff members to complete the questionnaire, including but not limited to:
    1. Teaching Staff/Home Visitor
    2. Site Managers
    3. Family Advocate
  3. Fax the completed questionnaires back to the appropriate SSI office named on the documents.
  4. Scan the completed questionnaire and add to child plus profile under the “Application” Tab, under “Attachments”.
  5. File the questionnaire in the child’s permanent record by following all HIPAA and FERPA rules.
  6. If the questionnaire is for a child no longer in our program, the Disability Services Coordinator will contact the Social Security Administration to inform them, and then shred the questionnaire.


Forms and Additional Guidance:

This policy complies with the following

Head Start Program Performance Standard:    
ODJFS Child Care Manual:    
CACFP Regulation:    
Caring for Our Children:    
Other Sources:   https://www.cdc.gov/phlp/publications/topic/healthinformationprivacy.html


Effective Date:   8/7/17 Reviewed Date:   3/17/20, 6/15/22
Approved By Policy Council:   8/7/17 Revision Approved By Policy Council:    
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