Form 4201, ECI Surrogate Parent Identification of Need and Assignment

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Effective Date

4/2017
4201.pdf
4201-S.pdf , 4201-S_instruct.pdf

 

Instructions

Updated: 4/2017

 

Purpose

Form 4201 is used to:

  • identify and document the reason a surrogate parent is needed, and
  • assign a surrogate parent.

Detailed Instructions

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.