This is an interesting scaffold to help teachers get more out of their use of technology. The teacher starts with an existing lesson plan and just tries to do the exact same thing with technology. Then they are asked to 'enhance' is via the SAMR stages.
The form includes a question about student process, which is effectively getting at the idea of moving from students as consumers to students are creators/remixers.
What PROCESS are you supporting during the activity at the Substitution stage?
I would not take the whole as is to run with, but I like several things. 1, all teachers have entry point, 2, all teachers have a next step, 3, focus on producing, 4, scalable, this would work for single lesson or a big project, and 5, it provides a mental structure a teacher could use afterwards on their own.