Appendix E: Team Member Rating Form (to be completely independently by each team member)
RE-AIM ASSESSMENT RATING FORM
This rating form was designed to be done after a preliminary team educational session on the use of RE-AIM in your Triple Aim QUERI project. Please rate each question below regarding the importance of and the need to enhance each RE-AIM dimension in your project. Use your best estimate to provide a 1-5 rating for each item even if you are not sure or do not feel you have quite enough information. Please refer to the documents provided to you through the preliminary meeting (RE-AIM measure table and RE-AIM handouts) to remind you how each dimension was operationalized in your project. Please use the comment section to qualify your ratings and make initial suggestions on how to enhance the given RE-AIM dimension.
REACH (to eligible Veterans)
1. How important is Reach to this project, at this time? ___
1 = not important
2=somewhat important
3= important
4=moderately important
5 = extremely important
2. How satisfied are you with progress to date on Reach? ____
1 = not satisfied
2=somewhat satisfied
3= satisfied
4=moderately satisfied
5 = extremely satisfied
3. Comments and Plans to Enhance Reach (as relevant):
Effectiveness (Primary outcomes and unintended consequences; impact on health equity)
1. How important is Effectiveness to this project, at this time? ___
1 = not important
2=somewhat important
3= important
4=moderately important
5 = extremely important
2. How satisfied are you with progress to date on Effectiveness? ____
1 = not satisfied
2=somewhat satisfied
3= satisfied
4=moderately satisfied
5 = extremely satisfied
3. Comments and Plans to Enhance Effectiveness (as relevant):
Adoption (Decision to participate by settings and staff)
1. How important is Adoption to this project, at this time? ___
1 = not important
2=somewhat important
3= important
4=moderately important
5 = extremely important
2. How satisfied are you with progress to date on Adoption? ____
1 = not satisfied
2=somewhat satisfied
3= satisfied
4=moderately satisfied
5 = extremely satisfied
3. Comments and Plans to Enhance Adoption (as relevant):
Implementation (Delivery fidelity and consistency; appropriate adaptations; costs)
1. How important is Implementation to this project, at this time? ___
1 = not important
2=somewhat important
3= important
4=moderately important
5 = extremely important
2. How satisfied are you with progress to date on Implementation? ____
1 = not satisfied
2=somewhat satisfied
3= satisfied
4=moderately satisfied
5 = extremely satisfied
3. Comments and Plans to Enhance Implementation (as relevant):
Maintenance (Sustainability for both setting and staff)
1. How important is Maintenance to this project, at this time? ___
1 = not important
2=somewhat important
3= important
4=moderately important
5 = extremely important
2. How satisfied are you with progress to date on Maintenance? ____
1 = not satisfied
2=somewhat satisfied
3= satisfied
4=moderately satisfied
5 = extremely satisfied
3. Comments and Plans to Enhance Maintenance (as relevant):
Other Comments and Notes: