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New York State Human Trafficking Referral Form

Referral of Trafficked Person

Social Services Law § 483-cc requires that this form be completed and sent to the Division of Criminal Justice Services and the Office of Temporary and Disability Assistance as soon as practicable after a first encounter with a person who reasonably appears to be a human trafficking victim. Referrals can only be made by law enforcement or an establish social/legal services provider. If you are an established social/legal services provider, you must obtain consent from the trafficked person prior to making the referral. Self-referrals or anonymous tips are not accepted. If you have experienced trafficking and need assistance, please contact a Response to Human Trafficking Program regional provider: Providers | Refugee Services | OTDA (ny.gov). 

Please contact the NYS Division of Criminal Justice Services by email at dcjs.human.trafficking.program@dcjs.ny.gov if you encounter difficulty completing or have questions regarding the form.

***After submission, you will not be able to view your entry. Please save work before submission in a secure location on your own device. 
This question requires a valid date format of MM/DD/YYYY.
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6. Please check one or both *This question is required.
8. Jurisdiction/Location Where Trafficking Occurred *This question is required.
11. If you are an established social/legal services provider, did you obtain the consent of the trafficked person? Pursuant to SSL section 483-cc(a), established social/legal services providers must obtain the consent of the trafficked person to submit a referral. Please submit a referral after speaking with the trafficked person and obtaining their consent. *This question is required.
12. Is the victim willing to assist in the investigation/prosecution of trafficker(s)? *This question is required.
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