I. Screening logistics

1. Who to screen:
   1. Screen all patients.
   2. Screen parents or legal guardians of patients under the age of 18 for human trafficking.
   3. Screening questions for human trafficking are found in part III below
2. Who should complete screening:
   1. Health care providers should screen for human trafficking. 
      1. Health care providers include: doctors, podiatrists, dentists, chiropractors, clinical psychologists, optometrists, nurse practitioners, nurse-midwives, and clinical social workers.  
3. When to screen:
   1. Opportunities for providers to screen patients include:
      1. All adult and adolescent inpatient encounters by use of the human trafficking screening questions on the nursing assessment form;
      2. Health maintenance exams;
      3. The onset of care for a new chronic disease;
      4. Pregnancy and postpartum visits; and
      5. Any other occasion where signs and symptoms warrant screening.
4. Screen in a safe environment:
   1. Screening must occur in private. THE PATIENT MUST BE ALONE.
      1. Friends, relatives, and any other accompanying person and children that are of verbal age should not be present since confidentiality may be compromised, the safety of the patient may be jeopardized, and accurate information may not be obtained.
      2. If privacy is not possible, do not screen but document the efforts made and the reason for not screening in the medical record.
      3. Techniques that may be useful to get the patient alone for a screening including escorting the patient to the bathroom, having a health facility policy that all intakes are done with the patient alone, or sending the person accompanying the patient on an errand (e.g., completing a form, getting the patient a glass of water or ice)
      4. If patient needs a translator, do not use the patient’s family member, friend, or intimate partner as the translator. 
         
         

II. Assessing clinical indicators

1. Given the limited number of studies on human trafficking, the information needed to adequately list the clinical indicators is unavailable. However, the following have been identified as potential indicators of human trafficking(1):
2.  

General Indicators	Labor Trafficking	Sex Trafficking
Scripted or inconsistent history Unwilling or hesitant to answer questions about the injury or illness Accompanied by person who does not let patient speak for themselves Evidence of controlling or dominating relationships Fearful/nervous behavior/avoids eye contact Resistant to assistance or demonstrates hostile behavior Unable to provide their address Not aware of their location/current date or time Not in possession of identity documents Not in control of their own money Not being paid or wages are being withheld.	Has been abused at work or threatened with harm by an employer or supervisor Is not allowed to take adequate breaks, food, or water while at work. Is not provided with adequate personal protective equipment for hazardous work. Was recruited for different work than they are currently doing. Is required to live in housing provided by employer. Has a debt to employer or recruiter that they cannot pay off.	Patient is under the age of 18 and is involved in the commercial sex industry. Reports unusually high numbers of sexual partners

1. 1. Health Indicators
      1. Physical Health

1. Signs of physical abuse or unexplained injuries Bruising, burns, cuts or wounds, blunt force trauma, fractures, broken teeth, signs of torture	5. Dietary health issues Severe weight loss, malnutrition, loss of appetite
2. Neurological conditions Traumatic brain injury, headaches or migraines, unexplained memory loss, vertigo of unknown etiology, insomnia, difficulty concentrating	6. Reproductive issues Sexually-transmitted infections, genitourinary issues, repeated unwanted pregnancies, forced or pressured abortions, genital trauma, sexual dysfunction, retained foreign body
3. Cardiovascular/respiratory conditions that appear to be caused or worsened by stress, such as Arrhythmia, high blood pressure, acute respiratory distress	7. Substance abuse disorders Alcohol abuse or misuse, opioid abuse, other illicit drug abuse
4. Gastrointestinal conditions that appear to be caused or worsened by stress, such as Constipation, irritable bowel syndrome	8. Other Effects of prolonged exposure to extreme temperatures or to industrial/agricultural chemicals, repetitive motion injuries from repeated tasks (e.g., hair braiding, agriculture, manufacturing), somatic complaints

It is also important to highlight any internal reporting processes (e.g., security, social work)

NOTE: If a patient presents for treatment for an injury due to violence, the patient should be told that by law we are required to make a report to [Insert any internal reporting policy] and to the police. 

1. 1. 1. 2. Mental Health

1. Depression	6. Flashbacks	11. Attachment disorders
2. Suicidal Ideation	7. Lack of emotional responsiveness	12. Depersonalization or derealization
3. Self-harming behaviors	8. Feelings of shame or guilt	13. Dissociative disorders
4. Anxiety	9. Hypervigilance
5. Post-traumatic stress disorder	10. Hostility

2. 1. 1. 3.  Social/Developmental
            1. Increased engagement in high risk behaviors, such as running away or early sexual initiation if a minor
            2. Trauma bonding with trafficker or other victims
            3. Difficulty establishing or maintaining healthy relationships
            4. These can be tailored to your institution and altered as research and validation of screening questions grows.
            5. Impaired social skills
               
               

III. Screening questions guidelines (adopted from Vera Institute Short Tool)

1. Screening questions will be asked in a non-judgmental, direct manner:
   1. Framing statements may be used as a lead-in to the screening questions to avoid the patient’s perception of being singled out as a potential human trafficking victim:
      1. “Because violence is so common in many people’s lives, I routinely ask all of my patients about it.”
      2. “I don’t know if this is a problem for you, but many people I see are dealing with an abusive relationship, so I ask about partner and employer violence routinely.”
2. The following questions may be used to screen for human trafficking:
   1. Have you worked for someone or done any other activities for which you thought you would be paid? Have you ever worked without getting the payment you thought you would get ?
      1. This could include activities like unpaid domestic work that might not be readily defined as “work” and should only detail those jobs in which the person felt unsafe or did not get paid what the person felt they should.
      2. If “yes” to either question – What kind of work or activities were you doing? How did you find out about these jobs/activities?
   2. Did anyone where you worked (or did other activities) ever trick or pressure you into doing anything you did not want to do? Did you ever feel like you could not leave?
      1. If “yes” – Could you tell me why you couldn’t leave? What did you think would happen to you if you left? Could you please give me some examples?
   3. Did you ever have sex for things of value (for example money, housing, food, gifts, or favors)?
      1. If “yes” – were you pressured to do this? Were you under age 18 when this occurred?
   4. Did anyone take and keep your identification, for example, your passport or driver’s license?
      1. If “yes” – could you get them back if you wanted?
   5. Were you recruited by your employer to do work different than you actually perform? 
      1. If “yes” – Did you want to leave after learning that you would be doing different work? Were you unable to leave? Did you fear something would happen to you if you left? 
   6. Are you required to live in housing provided by your employer?
      1. If “yes” – Do you feel safe in the housing? Did you ever want to leave? If so, why have you not left? 
   7. Do you have a debt to your employer or recruiter that you cannot pay off?
      1. If “yes” – How did you become indebted to your employer or recruiter? 
3. When unable to converse fluently in the patient’s primary language:
   1. The patient’s family, friends or children may not be used as interpreters when asking about human trafficking.
   2. Use a professional interpreter or another healthcare provider fluent in the patient’s language. If an interpreter assists with obtaining information, that fact along with the name of the interpreter will be documented in the medical chart.
   3. If a professional interpreter or healthcare provider is not available, do not screen.

IV. If the patient denies trafficking and:

1. Your assessment does not have conflicting indicators, document a negative screen.
2. With a positive screen it is important to redirect healthcare providers to a response policy and/or resources for responding (e.g., request a social work consultation for further assessment and resources)
3. Your assessment does not have conflicting indicators and the above question was posed to the patient who then discloses abuse, [Insert response policy per healthcare facility protocol] .
   
   

V. If the patient screens positive for human trafficking (answers yes to ANY of the screening questions)

1. Give the patient a validating message:
   1. You do not deserve to be treated this way.
   2. You are not to blame.
   3. Help is available for you.
   4. There is no excuse for human trafficking.
   5. No one deserves to be abused/taken advantage of.
   6. You are not alone. There are people you can talk to for support, shelter and legal advice. This could be a social worker, abuse referral team member, office manager, etc.
   7. It must be very difficult for you.
2. Contact [Appropriate health facility resource] to determine if a report must be made under Michigan Law, and to refer the patient to the appropriate community agency or Resource.

CITATIONS

(1) Identifying Victims of Human Trafficking: What to Look for in Health Care Settings, National Human Trafficking Resource Center and SOAR, https://www.acf.hhs.gov/sites/default/files/otip/soar_nhtrc_what_to_look_for_in_health_care_settings.pdf.