ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


ASSESSMENT 
DATE: 
AGENCY 
NAME: 


ADDRESS: 


TELEPHONE: 
E-MAIL: 
STAFF 
INTERVIEWED: 


INTERVIEWERS: 


SEND 
REPORT 
TO: 


CONNECTION 
AND 
READINESS 


1. 
Describe 
the 
relationship 
and 
networking 
between 
your 
agency 
and 
the 
local 
rape 
crisis 
center. 
Describe 
any 
specific 
outreach 
efforts 
or 
networking 
agreements. 
2. 
How 
does 
your 
collaboration 
with 
rape 
crisis 
centers 
improve 
your 
readiness 
to 
serve 
women 
with 
disabilities 
who 
experience 
sexual 
violence 
and 
the 
broader 
community 
(e.g., 
police, 
court)? 
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ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


3. 
How 
would 
a 
woman 
with 
a 
disability 
who 
experienced 
sexual 
violence 
know 
she 
could 
safely 
disclose 
to 
staff 
in 
your 
agency? 
Describe 
any 
specific 
awareness 
efforts. 
4. 
Describe 
how 
agency 
materials 
and 
environment 
make 
it 
known 
that 
the 
agency 
is 
a 
safe 
place 
for 
women 
with 
disabilities 
to 
talk 
about 
sexual 
violence. 
5. 
How 
are 
staff 
prepared 
to 
respond 
to 
disclosures 
of 
sexual 
violence? 
Describe 
staff 
attitude 
regarding 
disclosures. 
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ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


6. 
Describe 
staff 
development 
opportunities 
regarding 
sexual 
violence. 
How 
much 
training 
is 
provided? 
How 
much 
is 
required? 
How 
are 
rape 
crisis 
centers 
included 
as 
trainers? 
Describe 
training 
approaches 
that 
enhance 
staff 
comfort 
and 
confidence 
in 
responding 
to 
sexual 
violence. 
Training 
Topics 
Number 
of 
Hours 
Per 
Year 
Sexual 
violence 
and 
women 
with 
disabilities 
(incidence, 
impact, 
general 
information) 
• 
Yes 
• 
No 
Impact 
of 
sexual 
violence, 
injury, 
trauma, 
etc. 
• 
Yes 
• 
No 
Responding 
to 
disclosures 
• 
Yes 
• 
No 
System 
response/resources 
(emergency 
department, 
law 
enforcement, 
criminal 
justice 
system) 
to 
sexual 
violence 
• 
Yes 
• 
No 
Agency 
policies 
& 
procedures 
guiding 
service 
to 
women 
with 
disabilities 
who 
experience 
sexual 
violence 
• 
Yes 
• 
No 
Other 
• 
Yes 
• 
No 


8. 
CONNECTION 
AND 
READINESS 
SUMMARY 
Strengths: 
Challenges: 


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ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


Resources 
Needed: 


POLICIES 
AND 
PRACTICES 


1. 
How 
do 
you 
inform 
women 
with 
disabilities 
about 
healthy 
sexuality, 
sexual 
relationships 
and 
their 
rights 
to 
sexual 
safety? 
2. 
Describe 
agency 
policy 
regarding 
personal 
boundaries 
among 
clients 
and 
between 
clients 
and 
staff. 
How 
does 
policy 
explain 
what 
it 
means 
to 
respect 
personal 
boundaries 
and 
the 
agency’s 
response 
to 
boundary 
violations? 
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ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


3. 
How 
does 
agency 
intake 
protocol 
include 
screening 
for 
history 
of 
sexual 
violence? 
How 
does 
ongoing 
service 
planning 
and 
delivery 
provide 
disclosure 
opportunities 
for 
women 
who 
experience 
sexual 
violence? 
4. 
How 
do 
you 
inform 
women 
with 
disabilities 
about 
how 
to 
report 
if 
they 
experience 
sexual 
harassment 
or 
sexual 
violence? 
How 
do 
staff 
educate 
women 
with 
disabilities 
regarding 
required 
reporting 
(at 
point 
of 
intake 
and 
any 
point 
of 
potential 
disclosure)? 
5. 
Describe 
immediate 
response 
to 
women 
with 
disabilities 
who 
disclose 
sexual 
violence 
(e.g., 
crisis 
intervention, 
medical 
care, 
reporting 
and 
safety 
planning). 
How 
does 
the 
response 
to 
disclosure 
support 
victim 
safety 
and 
healing? 
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ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


6. 
How 
is 
privacy 
provided 
when 
a 
woman 
with 
a 
disability 
discloses 
sexual 
violence? 
7. 
How 
does 
the 
woman 
participate 
in 
reporting 
sexual 
violence 
to 
others 
(e.g., 
family, 
rape 
crisis 
center, 
OIG, 
law 
enforcement)? 
8. 
Describe 
referral 
process 
and 
coordination 
of 
services 
with 
rape 
crisis 
center. 
How 
would 
a 
woman 
be 
informed 
that 
she 
can 
use 
rape 
crisis 
services? 
Does 
agency 
provide 
on-site 
space 
for 
rape 
crisis 
staff 
to 
serve 
women 
with 
disabilities? 
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ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


9. 
How 
does 
the 
service 
plan 
incorporate 
a 
holistic 
response 
to 
the 
woman’s 
sexuality, 
sexual 
orientation, 
sexual 
choices 
and 
safety? 
10. 
How 
is 
understanding 
of 
and 
response 
to 
trauma 
integrated 
into 
the 
overall 
service 
plan 
(e.g., 
education, 
employment, 
counseling)? 
11. 
How 
does 
staff 
advocate 
for 
and/or 
arrange 
transportation 
and 
accommodations 
for 
individual 
women 
with 
disabilities 
in 
the 
agency 
and 
community 
settings 
(e.g., 
hospital, 
court)? 
7 



ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


12. 
POLICIES 
AND 
PRACTICES 
SUMMARY 
Strengths: 
Challenges: 


Resources 
Needed: 


8 



ILLINOIS 
IMAGINES 
TRAUMA 
RESPONSIVENESS 
ASSESSMENT 
TOOL 


ADDITIONAL 
RESOURCES 


1. 
What 
resources 
(e.g., 
training, 
etc.) 
do 
you 
need 
to 
be 
more 
trauma 
responsive? 
2. 
COMMENTS: 
9