ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


ASSESSMENT 
DATE: 
AGENCY 
NAME: 


ADDRESS: 


TELEPHONE: 
E-MAIL: 
STAFF 
INTERVIEWED: 


INTERVIEWERS: 


SEND 
REPORT 
TO: 


CONNECTION 
AND 
READINESS 


1. 
How 
does 
your 
agency 
recruit 
employees, 
volunteers 
and 
board 
members 
who 
have 
disabilities? 
How 
is 
agency 
composition 
representative 
of 
the 
demographics 
of 
the 
service 
area 
(per 
census 
data)? 
2. 
How 
is 
the 
agency 
environment 
welcoming 
and 
accessible 
to 
clients, 
staff, 
board 
and 
volunteers 
with 
disabilities 
(e.g., 
art 
work 
and 
other 
dιcor, 
magazines 
and 
books 
in 
public 
areas, 
arrangement 
of 
furniture)? 
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ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


3. 
How 
do 
agency 
materials 
indicate 
that 
accommodations 
(e.g., 
interpreters, 
adapted 
communication) 
will 
be 
provided 
for 
women 
with 
disabilities? 
4. 
How 
does 
your 
collaboration 
with 
disability 
service 
agencies 
improve 
your 
readiness 
to 
serve 
women 
with 
disabilities 
and 
the 
broader 
community 
(e.g., 
hospital, 
police, 
court)? 
5. 
How 
would 
a 
disability 
service 
agency 
know 
that 
your 
agency 
welcomes 
women 
with 
disabilities 
as 
clients? 
Describe 
any 
specific 
awareness/outreach 
networking 
efforts. 
6. 
How 
would 
a 
woman 
with 
a 
disability 
who 
experienced 
sexual 
violence 
know 
she 
could 
receive 
services 
from 
your 
agency? 
Describe 
any 
specific 
awareness/outreach 
efforts. 
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ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
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7. 
Describe 
staff 
development 
opportunities 
regarding 
serving 
women 
with 
disabilities. 
How 
are 
women 
with 
disabilities 
and/or 
disability 
service 
providers 
included 
as 
trainers? 
Describe 
approaches 
that 
enhance 
staff 
comfort 
and 
confidence 
in 
working 
with 
women 
with 
disabilities. 
Training 
Topics 
Number 
of 
Hours 
Per 
Year 
Women 
with 
disabilities 
and 
sexual 
violence 
incidence/impact/general 
information 
• 
Yes 
• 
No 
Types 
of 
disabilities 
• 
Yes 
• 
No 
Accommodations 
for 
different 
abilities 
• 
Yes 
• 
No 
Service 
planning 
and 
delivery 
with 
women 
with 
disabilities 
• 
Yes 
• 
No 
Crisis 
response 
to 
disclosure 
of 
sexual 
violence 
• 
Yes 
• 
No 
Agency 
capacity 
to 
serve 
women 
with 
disabilities 
• 
Yes 
• 
No 
Agency 
policies 
& 
procedures 
guiding 
service 
to 
women 
with 
disabilities 
• 
Yes 
• 
No 
Other 
• 
Yes 
• 
No 


9. 
CONNECTIONS 
AND 
READINESS 
SUMMARY 
Strengths: 
3 



ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


Challenges: 


Resources 
Needed: 


POLICIES 
AND 
PRACTICES 


1. 
How 
do 
agency 
policies, 
practices 
and 
budget 
demonstrate 
commitment 
to 
serving 
women 
with 
disabilities? 
2. 
How 
do 
current 
policies 
and 
practices 
accommodate 
the 
various 
needs 
of 
women 
with 
disabilities 
(e.g., 
communication 
tools, 
service 
animals, 
physical 
access)? 
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ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


3. 
How 
do 
emergency 
evacuation 
procedures 
ensure 
safety 
of 
women 
with 
disabilities? 
4. 
How 
do 
policies 
and 
practices 
create 
challenges 
in 
serving 
women 
with 
disabilities? 
5. 
How 
does 
the 
agency 
serve 
women 
with 
disabilities 
who 
request 
off-site 
services? 
Describe 
the 
challenges 
associated 
with 
providing 
off-site 
services. 
6. 
How 
would/do 
women 
with 
disabilities 
know 
that 
off-site 
services 
are 
available? 
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ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


7. 
How 
does 
staff 
advocate 
for 
and/or 
arrange 
transportation 
and 
accommodations 
for 
individual 
women 
with 
disabilities 
in 
both 
agency 
and 
community 
settings? 
8. 
Are 
there 
particular 
intake 
questions 
that 
invite 
survivors 
to 
disclose 
and/or 
discuss 
any 
disability 
and 
need 
for 
accommodation? 
How 
would 
staff 
know 
a 
woman 
has 
a 
disability, 
if 
not 
obvious, 
and 
her 
particular 
needs 
in 
relation 
to 
any 
disability? 
9. 
What 
specific 
guidance 
and 
supervision 
do 
staff 
receive 
regarding 
victim-centered 
service 
planning 
and 
delivery 
for 
a 
woman 
with 
a 
disability 
(e.g., 
communication 
techniques, 
empowering 
the 
survivor, 
working 
with 
guardians)? 
10. 
How 
are 
client 
materials/paperwork 
(e.g., 
intake 
form, 
service 
plan, 
evaluation 
of 
services) 
made 
available 
in 
alternative 
formats 
such 
as 
large 
print, 
pictures, 
simplified 
language? 
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ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


11. 
POLICIES 
AND 
PRACTICES 
SUMMARY 
Strengths: 
Challenges: 


Resources 
Needed: 


PHYSICAL 
ACCESS 


1. 
Does 
your 
agency 
have 
a 
parking 
lot? 
• 
Yes 
• 
No 
_____ 
number 
of 
spaces 
Does 
at 
least 
one 
parking 
space 
have 
at 
least 
8’ 
of 
clearance 
on 
side 
of 
the 
space 
(e.g. 
for 
a 
van). 
• 
Yes 
• 
No 


Are 
accessible 
spaces 
identified 
with 
signage? 
• 
Yes 
• 
No 


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ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


2. 
If 
you 
do 
not 
have 
a 
parking 
lot, 
is 
there 
accessible 
parking 
nearby? 
Are 
the 
accessible 
parking 
spaces 
closest 
to 
the 
accessible 
entrance? 
• 
Yes 
• 
No 
3. 
Is 
at 
least 
1 
entrance 
to 
the 
building 
accessible 
without 
using 
stairs? 
• 
Yes 
• 
No 
4. 
Does 
the 
accessible 
entrance 
provide 
direct 
access 
to 
the 
main 
floor 
or 
lobby? 
• 
Yes 
• 
No 
5. 
If 
the 
building 
has 
ramps 
to 
entrances, 
is 
the 
grade 
no 
steeper 
that 
1 
inch 
of 
slope 
for 
every 
12 
inches 
of 
ramp? 
• 
Yes 
• 
No 
6. 
Do 
all 
doors 
used 
by 
clients 
have 
at 
least 
a 
32-inch 
clear 
opening 
(include 
restrooms 
and 
offices)? 
• 
Yes 
• 
No 
7. 
Is 
there 
a 
threshold 
edge 
on 
each 
door 
that 
is 
less 
than 
1/4inch 
high, 
or 
a 
beveled 
edge 
no 
more 
than 
1/2inch 
high? 
• 
Yes 
• 
No 
8. 
Are 
door 
handles 
no 
more 
than 
48 
inches 
from 
the 
floor? 
• 
Yes 
• 
No 
9. 
Can 
doors 
be 
opened 
without 
having 
to 
grasp, 
twist, 
or 
turn 
a 
door 
handle? 
• 
Yes 
• 
No 
10. 
Can 
doors 
be 
opened 
without 
too 
much 
force 
(8.5lb 
for 
exterior 
and 
5lb 
for 
interior)? 
• 
Yes 
• 
No 
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IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


11. 
Are 
all 
pathways 
to 
service 
areas 
at 
least 
36 
inches 
wide? 
• 
Yes 
• 
No 
12. 
If 
there 
are 
stairs 
between 
any 
essential 
public 
areas, 
are 
there 
also 
ramps 
or 
elevators 
to 
those 
areas? 
• 
Yes 
• 
No 
13. 
If 
there 
is 
an 
elevator 
in 
the 
building, 
is 
the 
call 
button 
no 
higher 
than 
42 
inches 
from 
the 
floor? 
• 
Yes 
• 
No 
14. 
Do 
the 
buttons 
in 
the 
elevator 
cab 
have 
raised/Braille 
lettering? 
• 
Yes 
• 
No 
15. 
Are 
restroom 
doors 
and 
stall 
doors 
operable 
from 
both 
sides 
without 
grasping, 
twisting 
or 
turning? 
• 
Yes 
• 
No 
16. 
Is 
there 
an 
accessible 
stall 
with 
a 
clear 
area 
of 
at 
least 
5ftX5ft 
from 
the 
door 
swing? 
Is 
there 
a 
stall 
that 
is 
less 
accessible, 
but 
offers 
more 
space 
than 
a 
standard 
stall? 
• 
Yes 
• 
No 
17. 
Are 
there 
grab 
bars 
secured 
onto 
the 
wall 
behind 
the 
toilet 
and 
on 
the 
side 
wall 
nearest 
to 
it 
in 
the 
accessible 
stall? 
• 
Yes 
• 
No 
18. 
Is 
there 
clearance 
space 
beneath 
at 
least 
1 
sink 
for 
someone 
using 
a 
wheelchair 
to 
roll 
safely 
up 
to 
the 
sink? 
• 
Yes 
• 
No 
19. 
Can 
the 
faucets 
be 
operated 
without 
grasping, 
twisting 
or 
turning? 
• 
Yes 
• 
No 
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ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


20. 
Are 
soap 
dispensers, 
hand 
dryers 
or 
towel 
dispensers 
no 
more 
than 
48 
in. 
from 
the 
floor 
and 
operable 
without 
grasping 
twisting 
or 
turning? 
• 
Yes 
• 
No 
21. 
During 
times 
of 
inclement 
weather, 
are 
ice 
and 
snow 
removed 
from 
sidewalks, 
curb 
cuts 
and 
building 
entrances? 
• 
Yes 
• 
No 
22. 
How 
do 
you 
accommodate 
clients 
with 
environmental 
sensitivities 
(e.g., 
florescent 
lighting, 
chemicals, 
fragrances)? 
23. 
PHYSICAL 
ACCESS 
SUMMARY 
Strengths: 
10 



ILLINOIS 
IMAGINES 
DISABILITY 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


Challenges: 


Resources 
Needed: 


ADDITIONAL 
RESOURCES 


1. 
What 
resources 
do 
you 
need 
to 
enhance 
agency 
response 
to 
women 
with 
disabilities 
who 
experience 
sexual 
violence? 
2. 
COMMENTS: 
11