Form 1 RFA Draft

Request for Assistance

OMB Control Number: 0970-0362
Expiration Date: 02/28/2018

for Child Victims of Human Trafficking

The Trafficking Victims Protection Act of 2000 (TVPA), as amended, requires federal, state, and local officials to notify the U.S. Department of
Health and Human Services (HHS) not later than 24 hours after discovering that a foreign national minor may be a victim of trafficking (22
U.S.C. § 7105 (b)). This Request for Assistance form (RFA) should be used to notify HHS of trafficking concerns for a foreign national minor
(non-U.S. citizen or non-lawful permanent resident under the age of 18) who is currently in the United States and request assistance on
behalf of the child (foreign national minor). Use of this form, or the completion of any section of this form, is optional.

PROCESS FOR REQUESTING ASSISTANCE
A

B

If there is credible information that a foreign national minor may have been subjected to forced labor
and/or commercial sex, complete and email Part A (pages 3, 4, and 5) as a password protected
PDF to [email protected] within 24 hours of discovering the potential trafficking
concerns. Do not include any of the child's identifying information in the subject line or body of the
email. HHS will acknowledge receipt of the RFA within one business day and will provide the
requester with a five-digit tracking number in the subject line of the email response.
Use Part B (pages 6 and 7) to provide additional information related to the child's experience of
forced labor and/or commercial sex. If the information for Part B is available within the initial 24
hours, submit the entire RFA (Part A and Part B) or wait to submit Part B until more
information is available. If submitted separately, submit Part B in the same manner as Part A and
include the five-digit tracking number in the subject line of the email that was provided during the
submission of Part A. HHS may request additional information at any point during the RFA process
for the purpose of determining whether the child is a victim of a severe form of trafficking in persons.

ISSUANCE OF ELIGIBILITY LETTERS
ELIGIBILITY LETTER
If there is sufficient information during the RFA process to indicate that the child was subjected to forced
labor and/or commercial sex, HHS will issue an Eligibility Letter, making the child eligible to apply for benefits
and services to the same extent as a refugee.
INTERIM ASSISTANCE LETTER
If there is information during the RFA process to indicate that the child may have been subjected to forced labor
and/or commercial sex, HHS will issue an Interim Assistance Letter, making the child eligible to apply for benefits
and services to the same extent as a refugee for up to 90 days (or 120 days, if extended). During this interim
assistance period, HHS will seek consultation from the U.S. Departments of Justice (DOJ) and Homeland Security
(DHS) and non-governmental organizations (NGOs) before issuing an Eligibility Letter or a Denial Letter.
DENIAL LETTER
If the information HHS receives during the RFA process does not indicate that the child may have been subjected
to a severe form of trafficking in persons, HHS will issue a Denial Letter to the child. HHS will include instructions
with the letter on how to request reconsideration or how to resubmit the child's case.

QUESTIONS ABOUT THE RFA PROCESS OR WANT TO DISCUSS A POTENTIAL CASE?

Contact HHS by phone at 202-205-4582 or email at [email protected] to ask questions regarding the RFA
process or to discuss potential cases before submitting an RFA on behalf of a child.

NATIONAL HUMAN TRAFFICKING HOTLINE

The National Human Trafficking Hotline (NHTH) at 1-888-373-7888 is also available 24 hours a day, 7 days a week to
assist trafficking victims to connect to available services.
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 1 hour 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.

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Request for Assistance

OMB Control Number: 0970-0362
Expiration Date: 02/28/2018

for Child Victims of Human Trafficking
INSTRUCTIONS | PART A
SECTION 1

Fill out the requester's information (individual submitting the RFA on behalf of the child) and their organization's
information, if applicable. HHS will use this information to correspond with the requester during the RFA process and
will send any letters issued to the child to the address provided. To ensure delivery, provide a full street address
instead of a P.O. box.

SECTION 2

Provide all available and applicable information on the child's behalf. If information is not available for a field, leave it
blank. For Documentation of Citizenship and Age, identify the type of document attached with the RFA, if
available. If the child has Continued Presence or a T visa, check Immigration Document and attach a copy with
the RFA. For Contact Information for Child's Representative/Attorney, provide the email address and phone
number of the child's representative or attorney. For Benefits Start Date (optional/if applicable), provide the
preferred date for the child's benefits to begin on the Interim Assistance or Eligibility Letter, which should be no later
than two weeks from the date of submission of the RFA.

SECTION 3

Indicate whether the potential trafficking concerns for the child are labor, sex, both labor and sex, or if there are
some other type of potential trafficking concerns (child in the midst of a possible trafficking scheme, child brought to
a location for the purpose of forced labor or commercial sex, etc.). For concerns of labor trafficking, also check
any indicators of force, fraud, or coercion experienced by the child in relation to the labor or service performed.
Note that the service performed by the child can also be sexual in nature (i.e. sexual servitude). For concerns of sex
trafficking, check whether there was an offer or exchange of something of value in relation to the sex act that the
child was asked or made to perform. In the box at the bottom of the page, describe the basis of the concern that the
child may be a victim of a severe form of trafficking and provide any relevant information supporting this concern.

SECTION 4

As the requester submitting the information on behalf of the child, review, sign, and date the form accordingly.

INSTRUCTIONS | PART B
SECTION 5

Provide additional supporting information regarding the trafficking concerns for the child, the basis of the concern
that the child may be a victim of trafficking, as well as any other applicable details. Refer to the federal definitions
provided under the narrative box on page 6 to inform the description.

SECTION 6

Completion of Section 6 is optional.

Severe Forms of Trafficking in Persons Involving Minors
Sex Trafficking: The child was recruited, harbored, transported, provided,
obtained, patronized, or solicited for the purpose of a commercial sex act
(person induced to perform such act has not attained 18 years of age).
Labor Trafficking: The child was recruited, harbored, transported, provided,
or obtained 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.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 1 hour 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.

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Part A | Request for Assistance
Submit within 24 hours of identifying potential trafficking concerns.

(1) REQUESTER'S INFORMATION

Complete all available and applicable information below.

Last Name:

First Name:

Title of Requester:
Name of Organization:
Address of Organization:
City:
State:

Zip Code:

Phone:
Email Address:

(2) CHILD'S INFORMATION

Complete all available and applicable information below.

Last Name:

First Name:

Middle/Other Name:

Sex:

Male
Female

Date of Birth:

Alien Number:

(MM/DD/YYYY)

Country of Origin:
Documentation of
Citizenship and Age:

Passport

Birth Certificate

Immigration Document

Other

None

Contact Information for
Representative/Attorney:
Benefits Start Date:
Language(s) Spoken:

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Part A | Request for Assistance
Submit within 24 hours of identifying SRWHQWLDOtrafficking concerns.

(3) POTENTIAL TRAFFICKING CONCERNS

Check and describe the potential concerns of labor and/or sex trafficking for the child below.

LABOR TRAFFICKING : Child made to perform labor or service(s)
Check all boxes that describe what the child experienced in relation to the labor or service(s).
Beatings, physical abuse, sexual assault, confinement, supervision, or monitoring
False offers of employment, love, marriage, or a better life
Change in work environment, work conditions, or compensation
Threat of serious harm against the child or others, witness of harm to others, climate of fear, threatened abuse of
legal system, or perceived threat of harm for non-compliance
Requirement to pay off a real or alleged debt
Requirement to pay off an increasing debt or a debt that changes over time
Other (Describe in the box at the bottom of this page.)

SEX TRAFFICKING : Child was asked or made to perform sex act(s)
Check all boxes that relate to the child being asked or made to perform the sex act(s).
Offer, promise, or exchange of something of value (money, food, shelter, etc.) to the child
Offer, promise, or exchange of something of value (money, food, shelter, etc.) to a person other than the child
Other (Describe in the box at the bottom of this page.)

What is the basis of the trafficking concerns indicated in the boxes checked above?

Provide the available information that indicates the child may be a victim of trafficking in the box below. If all of the
information related to the trafficking concerns is available, the requester may choose to submit the narrative in Part B,
Section 5 (page 6) with Part A.

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Part A | Request for Assistance
Submit within 24 hours of identifying potential trafficking concerns.

(4) INFORMATION SHARING AND CONSENT
Use of Child's Personal Information during RFA Process

HHS is responsible for identifying and assisting potential victims of human trafficking. HHS issues Eligibility Letters to
foreign national minor victims of trafficking, making the child eligible to apply for benefits and services to the same
extent as a refugee. During the RFA process, HHS will ask for personal information, such as the child's name, alien
number, and information about the child's experiences, to determine the child's eligibility for federal benefits as a
victim of human trafficking.
HHS will use information collected in the RFA to determine a child's eligibility for interim and long-term assistance (22
U.S.C. 7105(b)(1)(G)). Information gathered by HHS pursuant to an RFA enables HHS 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. HHS will make information available to non-HHS entities only for
the purposes described above and to comply with the TVPA.
If HHS provides interim assistance to a potential child trafficking victim, the TVPA requires HHS to notify DOJ and DHS
within 24 hours and to consult with DOJ, DHS, and NGOs with expertise on victims of trafficking prior to determining the
child's eligibility as a victim of trafficking (22 U.S.C. 7105(b)(1)(G)). With the requester's consent, HHS will provide
contact information for the requester to DOJ and DHS. If DOJ or DHS initiates an investigation or requests to speak
with the child regarding the crime of human trafficking, HHS 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 (22 U.S.C. § 7105 (b)(1)(G)).

Security of Child's Personal Information

The personally identifiable information (PII) that is shared with HHS throughout the Request for Assistance process will
be stored securely. The PII will be destroyed no later than 10 years after the minor's case is closed, unless required for
business use by HHS. HHS will use the information to evaluate and determine the child's eligibility for benefits, for
consultation purposes, for reporting requirements, and for research and analysis in anonymous datasets. Additionally,
there may be occasions when HHS will provide the information to respond to requests such as, Comptroller General
requests, HHS Inspector General requests or investigations, congressional subpoenas or requests, court orders, or
authorized disclosures. The information contained in the RFA may be disclosed for a legitimate law enforcement
purpose, including in response to a discovery request or otherwise in the course of criminal or civil litigation. To protect
the privacy of applicants, HHS will never share identifying information, such as the child's name or alien number, for
publicly available datasets or reports.

By signing this form, you acknowledge and understand that HHS will share the child's information as described above.
Additionally, you acknowledge that the information provided on this form and during the RFA process is credible and
accurate to the best of your knowledge, represents your recollections, and does not purport to record verbatim statements
from the potential child victim or other sources.

Today's Date:

Requester's Signature:

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Part B | Request for Assistance
Submit when information is available.

(5) NARRATIVE OF TRAFFICKING CONCERNS
What is the basis of the trafficking concerns that the child is a victim of trafficking?

When available, provide the narrative of information that indicates the child is a victim of trafficking, including involvement
with federal, state, or local law enforcement, if applicable. If the information is available, the requester may choose to
submit this narrative with Part A. If needed, refer to the definitions below.

Severe forms of trafficking in persons:
Labor trafficking: "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." (22 U.S.C. § 7102 (9))
Sex trafficking of a minor: "the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the
purpose of a commercial sex act." (22 U.S.C. § 7102 (10))
Commercial sex act: “any sex act on account of which anything of value is given to or received by any person.” (22 U.S.C. § 7102(4))
Coercion: “means (A) threats of serious harm to or physical restraint against any person; (B) 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 (C) the abuse or
threatened abuse of the legal process.” (22 U.S.C. § 7102(3))
Involuntary servitude: “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(6))
Abuse or threatened abuse of the legal process: “the use or threatened use of a law or legal process, whether administrative, civil, or
criminal, in any manner, or for any purpose for which the law was not designed, in order to exert pressure on another person to cause that
person to take some action or refrain from taking action.” (22 U.S.C. § 7102(1))
Peonage: “a status or condition of involuntary servitude based upon real or alleged indebtedness. (8 CFR 214.11)
Debt bondage: “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(5))
Sexual act: "means “(A) contact between the penis and the vulva or the penis and the anus, and for purposes of this subparagraph contact
involving the penis occurs upon penetration, however slight; (B) contact between the mouth and the penis, the mouth and the vulva, or the
mouth and the anus; (C) the penetration, however slight, of the anal or genital opening of another by a hand or finger or by any object, with an
intent to abuse, humiliate, harass, degrade, or arouse or gratify the sexual desire of any person; or (D) the intentional touching, not through the
clothing, of the genitalia of another person who has not attained the age of 16 years with an intent to abuse, humiliate, harass, degrade, or
arouse or gratify the sexual desire of any person.” ((18 U.S.C. § 2246(2))
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Part B | Request for Assistance

Submit when information is available.
(6) TRAFFICKING EXPERIENCE (optional)

Complete the information below related to the child's history and trafficking concerns. HHS may use the information below to
evaluate and determine the child's eligibility for benefits, for consultation purposes with law enforcement and NGOs, for reporting
requirements, and for research and analysis in anonymous datasets.

Context of Trafficker's Relationship with Child (Check all that apply.)
Acquaintance

Employer

Guardian/Caregiver

Spiritual/Religious Advisor

Coworker

Family Friend

Other

Sponsor

Current/Former Partner

Family Member/Relative

Political Party

Stranger

Current/Former Spouse

Friend

Recruiter

Unknown

Diplomat

Gang Member

Smuggler

Location(s) of Trafficking Incident(s) (List all countries where the trafficking incident(s) occurred.)

Child's Risk Factors History (Check all that apply across the child's lifetime.)
Assault

Low Income/Under Employed

Bullying

Mental Health Concern/Diagnosis

Child Maltreatment by Adult

Mental Illness in Household

Criminal Record

Mother Treated Violently

Debt

Parental Separation or Divorce

Disability (Developmental/Intellectual/Physical)

Physical Abuse

Distrust of Authorities

Physical Neglect

Emotional Neglect

Present in the United States without a Visa or Parole

Extortion/Ransom

Normalization of Exploitation

Family Member Involvement in Criminal Organization

Psychological or Emotional Abuse

Gang Presence/Community Crime

Runaway and Homeless Youth

Housing Instability/Homelessness

Sexual Abuse

Incarcerated Family Member

Sexual Victimization

Intimate Partner Violence

Substance Misuse in Household

Juvenile Justice Involved

Substance Use

Kidnapping

Witnessed or Indirect Victimization

Loss of Caregiver/Parent

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