Appendix E_CBO Readiness Assessment

CBO Readiness
Assessment
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Overview
This Readiness Assessment for CBO partners is designed to serve the following purposes:
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●
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Determine if a CBO is ready to begin implementation in Wave 1.
Begin to assess the scope of their implementation and determine how much support and
resources will be needed to onboard them to Unite Us.
Gather information to inform the wave deployment schedule and approach for Phase 2 of
the implementation (CBO engagement and onboarding).

Preview Assessment in SurveyMonkey
CBO Readiness Assessment in SurveyMonkey

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CBO Readiness Assessment
* Questions marked with an asterisk are required.

Section 1: Basic Information
Description: This assessment should be completed by a key decision maker at your organization in partnership with a representative from
the teams or departments that will be using the Unite Us software.
CBO Name:* (text box)
Please enter your information:*
● Name (text box)
● Title/role (text box)
● Email (text box)

Is your CBO national?* (one answer)
● Yes
● No

Where is your CBO located? If your CBO is national, please provide a list of all states that you anticipate will be using Unite Us in lieu of
“County,” “City,” and “Address(es.” *
● State (text box)
● County (text box)
● City (text box)
● Address(s) (text box)

Do you provide programs that address hypertension?* (one answer)
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●

Yes
No

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Are any departments/programs/locations from your CBO already using Unite Us?* (one answer)
● Yes
● No
If “Yes,” please identify which departments/programs/locations. (text box)

Are you prepared to complete necessary legal agreements, such as a Business Associate Agreement (BAA) for a Covered Entity, if
applicable?* (one answer)
● Yes
● No

Section 2: Readiness
Description: This section is designed to help your organization determine if you are ready to begin implementation with Unite Us.

Have you already identified a lead for the Unite Us project/implementation?* (one answer)
● Yes
● No
If “Yes,” please provide their contact information: (multiple text boxes)
● Name
● Email
● Phone Number

Do you have buy-in from leadership and future users of the Unite Us software?* (one answer)
● Yes
● No

Have you attended a Unite Us information session?* (one answer)

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Yes
No

Do you have goals or priorities for the utilization of the Unite Us software?* (one answer)
● Yes
● No
If “Yes,” please describe. (text box)

Section 3: Scope
Description: This section will help Unite Us determine the scope of the implementation for your organization and ensure the appropriate
amount of support and resources are available.

What is your desired time-frame to begin project work?* (multiple choice)
● Immediately
● In the next 1-3 months
● In the next 3-5 months
● After 5 months

Are you prepared to onboard within a 4 week timeline?* (one answer)
● Yes
● No
If “No,” please explain. (text box)

In addition to hypertension programs, are there other programs or teams that you would like to use Unite Us (at no cost)?* (one answer)
● Yes
● No
If “Yes,” please list the additional programs. (text box)

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Section 4: Users
Description: This section will ask questions about the staff members at your organization who will be using Unite Us (e.g. “users”).

Have you identified those staff who will be points of contact for each team or program that will be using Unite Us? This may be a team
supervisor or “super-user” (e.g. participate in workflow conversations, deliver communications to staff about roles/expectations, etc.).* (one
answer)
● Yes
● No

Do you have an estimated number of anticipated users?* (one answer)
● Yes
● No
If “Yes,” please insert the estimated number of users. (text box)

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