Form 2314-C, Consumer Satisfaction Interview Consumer Directed Services Addendum

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.


Effective Date: 5/2006


Updated: 5/2006


To serve as a monitoring tool to determine the Consumer Directed Services (CDS) individual's/family's satisfaction with the CDS agency and to evaluate the consumer's management of services. Form 2314-C serves as an addendum to Form 2314, Consumer Satisfaction Interview, which is completed per program monitoring requirements.


When to Prepare

After the CDS option is chosen and initiated, this form is completed at all monitoring contacts (90-day, six-month and annual), as required by the type service authorized. Complete Form 2314-C as long as the individual receives services under the CDS option. This form can be completed in person or by telephone with the individual based on requirements for the type of services authorized and monitoring action being completed.

Number of Copies

The reviewer completes an original copy.


The case manager files the original in the individual's case folder.

Form Retention

Keep the form according to the retention requirements of the case record.

Detailed Instructions

The case manager reviews with the individual or other respondent the top section of the form and completes it in full.

Individual— Enter the name of the individual receiving services.

Type of Service Delivered through CDS— Enter the type of services delivered through CDS — Primary Home Care (PHC), Family Care (FC), Community Attendant Services (CAS), Personal Assistance Services (PAS) or Respite.

Respondent— Enter the name of the person who is answering the questions. Check Individual, Employer or Designated Responsible Party (DRP) to indicate the respondent type.

Respondent's Relationship to Individual— Check Parent, Guardian or Other to indicate the relationship.

Reason for Contact— Enter the type of monitoring contact being completed (90-day, six-month or annual).

Date— Enter the date the form is completed with the CDS individual.

Name of CDS Agency— Enter the name of the CDS agency.

Provider No.— Enter the CDS agency provider number.

Detailed Questions for Assessing Consumer Satisfaction with the CDS Option

1.— Check Yes or No. If No, explain why the individual is dissatisfied with service delivery.

2.— Check Yes or No. If No, explain how the services are not being delivered according to the program authorization.

3.— Check Yes or No. If Yes, explain why the individual is not able to direct services and supervise attendants satisfactorily.

4.— Check Yes or No. If Yes, explain all problems reported to the CDS agency.

5.— Check Yes or No. If No, explain why the CDS option is not meeting the individual's needs.

6.— Check Yes or No. If neither party received a quarterly report, the case manager must follow up with the CDS agency.

7.— Check Yes or No. If Yes, explain any concerns or problems reported to the individual by the CDS agency this quarter.

Document any required follow up, as well as additional comments, if necessary.