- 4201-S.pdf (118.43 KB)
- 4201-S_instruct.pdf (13.56 KB)
Form 4201 is used to:
- identify and document the reason a surrogate parent is needed, and
- assign a surrogate parent.
File the original form in the child’s record. If a surrogate parent is assigned, provide a copy to the surrogate parent.
Note about Retention
Unless a longer period is required by state or federal law, the contractor must retain records for five years after the child has been dismissed from services.