ADMINISTRATION FOR CHILDREN AND FAMILIES
OFFICE OF REFUGEE RESETTLEMENT
ANTI-TRAFFICKING IN PERSONS DIVISION
Request for Assistance for Child Victims of Human Trafficking
This form may be used to request eligibility for federally funded assistance for a child victim of human trafficking.
An individual may use this form to request an Eligibility Letter for a non-U.S. citizen, non-lawful permanent resident child (under the age of 18) in the United States if the requestor believes the child may have been subjected to a severe form of trafficking in persons, as defined by the Trafficking Victims Protection Act of 2000, as amended (TVPA). An Eligibility Letter enables a child victim of human trafficking to receive federally funded benefits and services to the same extent as a refugee, including placement in the Unaccompanied Refugee Minors Program if no parent or legal guardian is available to care for the child. (See ORR State Letter #01-13 on the TVPA for more information.) ORR will review a completed form to determine whether a child is a victim of a severe form of trafficking and to assess child protection issues.
ORR may provide a letter of eligibility for interim assistance for a period of 90 days if ORR receives credible information that a child may have been subjected to trafficking, but wishes to consult with Federal law enforcement and nongovernmental organizations with expertise in victims of trafficking prior to making a determination of the child’s eligibility as a victim of trafficking. A child is not required to cooperate with law enforcement as a condition for receiving a letter of eligibility.
Submission of this form by e-mail to [email protected] or by fax to 202-401-5487 will facilitate ORR’s review of information indicating that a child needing assistance may have been subjected to trafficking in persons. An ORR Child Protection Specialist will respond to the requestor upon receipt and review of the request for assistance.
If ORR has not received sufficient information to make a determination of eligibility for either interim assistance or assistance as a victim of trafficking, ORR will notify the requestor regarding the status of the request within 10 business days after receipt of the request.
If within 30 calendar days of receipt of the request, ORR has not received sufficient information that a child may have been subjected to a severe form of trafficking in persons, ORR will issue a denial letter to the requestor. The requestor may appeal a denial of eligibility for assistance within 30 days of receipt of the decision by delivering or mailing a written notice of appeal to the HHS Departmental Appeals Board (DAB). The DAB will review appeals in accordance with DAB procedures set out in 45 C.F.R. Part 16.
Should additional information become available, the requestor should submit a new Request for Assistance form to ORR.
Important guidance regarding the trafficking questionnaire:
The Trafficking Questionnaire below should not be used as an intake form in the presence of the child. ORR recommends that the questionnaire be used as a resource for a requestor to review, upon believing that the child may be a victim of trafficking. The questionnaire’s language, drawn from statutory language, serves to help requestors consider whether a child may meet the statutory definition of a victim of a severe form of trafficking in persons.
Recognizing that requestors operate under various protocols, ORR strongly recommends that safe and appropriate methods of information gathering are employed; i.e., using professionals trained in interviewing children, reducing the number of interviews and possible retraumatization, and using child-friendly facilities, such as a child advocacy center, wherever possible.
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average one hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
ADMINISTRATION FOR CHILDREN AND FAMILIES
OFFICE OF REFUGEE RESETTLEMENT
ANTI-TRAFFICKING IN PERSONS DIVISION
Complete the Following:
Check boxes below to ensure all required information is completed.
Requestor Information
Child’s Information
Trafficking Questionnaire
Strengths/Needs of the Child
Statement of Severe Forms of Trafficking (optional)
Agency Verification and Consent to Information Sharing and signature
Requestor Information
The Requestor Information informs HHS about the requestor’s professional association. HHS reserves the right to collect further information regarding the requestor or organizational credentials.
Name of Organization/Agency:
Name & Staff Position of Requestor (Person Completing Form):
Requestor’s Contact Information:
Organization/Agency Contact Information (Address, Phone, Fax, Email; do not use PO Box):
Type of Organization:
State/local Child Welfare Agency
State/local Juvenile Justice Agency
State/local Law Enforcement Agency
Non-governmental organization
Federal Agency
Attorney of record/Legal service provider
Other
Child’s Information
Name (Last Name, First Name): Date of Birth: (MM/DD/YYYY) Sex: M F
Country of Origin: Specific Location of Origin i.e. town, state:
Does the child have proof of citizenship and age? Yes No
If the child has identifying documents (e.g., passport, birth certificate, immigration documents), attach copies.
If the child does not have identifying documents, provide explanation.
Does the child have a parent or parents in the U.S.? Yes No
Where do the child’s parents reside?
Does the child have non-parental relatives in the U.S.? Yes No
Has a non-parental adult or relative established legal responsibility for the child in the U.S.? Yes No If so, please provide explanation: ______________
Is the child pregnant? Yes No Is the child parenting? Yes No
Attorney of record for the child, if any, and attorney’s contact information:
Trafficking Questionnaire
While in the United States, was the child subjected to commercial sex, a form of labor trafficking, or both commercial sex and a form of labor trafficking?
Commercial Sex Labor Trafficking Both
Provide a brief (1-3 sentences) narrative describing the circumstances surrounding the type of commercial sex or labor trafficking the child was subjected to in the U.S.
If subjected to commercial sex, indicate all types below:
Commercial sex/prostitution on the street
Commercial sex/prostitution in a private residence
Commercial sex/prostitution in a place of business (restaurant, club, hotel, spa, massage parlor)
Pornography
Online commercial sexual exploitation
Newspaper advertisement of commercial sex
Online advertisement of commercial sex
Exotic dancing/stripping
Other
If subjected to labor trafficking through force, fraud or coercion, indicate all types below:
Agricultural work
Factory work
Begging/Street peddling
Domestic labor (cleaning, childcare, eldercare, etc., within a home)
Hospital, Assisted Living, or other facility-based patient care
Restaurant/bar work (serving, cooking, dishwashing, cleaning, etc.)
Janitorial work
Door-to-door sales
Construction work
Hair, nail, beauty salon
Other
If subjected to labor trafficking, indicate the method(s) of force, fraud, or coercion used to induce the child to engage in labor? Check all that apply.
Threats of serious physical or psychological harm
Threats of physical restraint
Threats of serious physical or psychological harm to the child’s family, friends, or associates
Threats of physical restraint against the child’s family, friends, or associates
Physical force against the child
Physical force against the child’s family, friends, or associates
Debt bondage (debt not reduced in a fair, reasonable manner, in accordance with the labor completed)
Lied to or misled about job opportunities
Kidnapping
Withholding of identification documents
Climate of fear (e.g., physical harm to someone else in the same circumstances)
Other (Please describe)
Who facilitated the ‘recruitment, harboring, transportation, provision, or obtaining’ of this child for the purpose of sex or labor trafficking? Check all that apply.
Smuggler (coyote, snakehead, etc.)
Pimp, panderer
Buyer of commercial sex, “John”
Employer
Co-worker
Family member
Spouse
Boyfriend/girlfriend
Close acquaintance
Stranger
Other
Describe and/or estimate the timeframe and duration of the trafficking situation.
Indicate where exploitation occurred i.e. cities, states.
How, when, and where was this child first identified as a possible victim of human trafficking?
How and when did this child come to your attention?
Has the trafficking situation been reported to local or State Child Protective Services? (Include date of report, name of reporter and, report identification number) What follow-up action, if any, did CPS take?
Has the trafficking situation been reported to local, State, or Federal law enforcement? (Include date of report, name of reporter, contact and agency that received report.) What follow-up action, if any, did law enforcement take?
Strengths/Needs of the Child
Please provide a brief overview of the child’s immediate needs (safety, shelter, medical care, family tracing, guardianship, etc.)
Please provide a brief overview of the child’s identified protective factors (case manager, family support, personal resiliency factors, etc.).
Statement of Severe Forms of
Trafficking (optional)
A Statement of Severe Forms of Trafficking is an optional summary that gives the requestor an opportunity to provide supplemental information supporting the process of determining a child is a victim of trafficking. A Statement may discuss in greater detail how the child arrived in the U.S., any separation from parents or legal guardians, circumstances surrounding the trafficking, or other exploitation experienced during the trafficking, etc. The Statement should be no more than one page in length and typed.
Agency Verification and Consent to
Information Sharing for
ORR Assistance to Child Trafficking
Victims
ORR will use information collected in the Request for Assistance to determine a child’s eligibility for interim and long-term assistance (See 22 U.S.C. 7105(b)(1)(F)). Information gathered by ORR pursuant to a Request for Assistance enables ORR to provide technical support to providers serving children and, when appropriate, to facilitate placement of unaccompanied child trafficking victims into the Unaccompanied Refugee Minors (URM) Program. Information gathered also contributes to the ORR Anti-Trafficking in Persons (ATIP) Division’s data on trafficking cases. ORR will make information available to non-HHS entities only for the purposes described above and to comply with the TVPA.
Such uses include the statutory requirements of notification to the U.S. Departments of Justice (DOJ) and Homeland Security (DHS) within 24 hours of the provision of interim assistance to a potential child trafficking victim and subsequent consultation with DOJ, DHS and non-governmental organizations with expertise on victims of trafficking prior to determining the child’s eligibility as a victim of trafficking. (See 22 U.S.C. 7105(b)(1)(F)(iv).) With the requestor’s consent, ORR/ATIP will provide contact information for a requestor to DOJ and DHS for follow-up. If DOJ or DHS initiates an investigation or requests to speak with the child regarding the crime of human trafficking, ORR encourages providers and law enforcement to coordinate with a child advocacy center or similar model to facilitate the interview. A child is not required to cooperate with law enforcement as a condition for receiving a letter of eligibility.
Requestor consents to ORR sharing information with ORR-approved users. Requestor verifies that all information provided is complete and accurate, to the best of his/her knowledge.
Requestor’s Signature ______________________________________ Date
Legal Definitions
When screening a potential child trafficking victim, a requestor should refer to legal definitions regarding child victims of a severe form of trafficking in persons, as laid out in the Trafficking Victims Protection Act (TVPA) of 2000, as amended, and in other criminal statutes.
Severe form of trafficking in persons means:
Sex trafficking in which…the person induced to perform a commercial sex act has not attained 18 years of age; or
“The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud or coercion, for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.” (emphasis added) (22 U.S.C. § 7102 (8))
Sex trafficking means “recruitment, harboring, transportation, provision or obtaining of a person for the purpose of a commercial sex act.” (22 U.S.C. § 7102(9))
Commercial sex act means “any sex act on account of which anything of value is given to or received by any person.” (22 U.S.C. § 7102(3))
Coercion means threats of serious harm to or physical restraint against any person; any scheme, plan, or pattern intended to cause a person to believe that failure to perform an act would result in serious harm to or physical restraint against any person; or the abuse or threatened abuse of the legal process. (22 U.S.C. § 7102(2))
Involuntary Servitude “includes a condition of servitude induced by means of—(A) any scheme, plan, or pattern intended to cause a person to believe that, if the person did not enter into or continue in such condition, that person or another person would suffer serious harm or physical restraint; or (B) the abuse or threatened abuse of the legal process.” (22 U.S.C. § 7102(5))
Peonage Section 1581 of Title 18 makes it unlawful to hold a person in "debt servitude," or peonage, which is closely related to involuntary servitude. Section 1581 prohibits using force, the threat of force, or the threat of legal coercion to compel a person to work against his/her will. In addition, the victim's involuntary servitude must be tied to the payment of a debt. (18 U.S.C. § 1581)
Debt bondage means “the status or condition of a debtor arising from a pledge by the debtor of his or her personal services or of those of a person under his or her control as a security for debt, if the value of those services as reasonably assessed is not applied toward the liquidation of the debt or the length and nature of those services are not respectively limited and defined.” (22 U.S.C. § 7102(4))
Slavery is defined as holding a person in a condition of slavery, that is, a condition of compulsory service or labor against his/her will. (18 U.S.C. § 1584)
| File Type | application/msword |
| Author | DHHS |
| Last Modified By | Bob |
| File Modified | 2009-04-10 |
| File Created | 2009-04-10 |