HSWAGATA BUDDHA TOOTH RELICS PRESERVATION MUSEUM
CONFLICT / GRIEVANCE REPORTING FORM
Form Code: HSW-F40
Case Number: __________________________
Date: ____ / ____ / ______
1. PERSON REPORTING
1.1 Name (optional if policy allows): __________
1.2 Role:
[ ] Staff [ ] Volunteer
[ ] Donor [ ] Visitor
[ ] Other: ____________________________
1.3 Contact (phone / email, optional):
______________________________________
2. PEOPLE INVOLVED IN THE ISSUE
(You may list more than one person.)
2.1 Name(s) and role(s):
______________________________________
______________________________________
3. TYPE OF ISSUE
(tick one or more)
[ ] Staff–staff conflict
[ ] Staff–volunteer conflict
[ ] Staff–donor or donor–staff
[ ] Staff–visitor or visitor–staff
[ ] Bullying / harassment
[ ] Discrimination
[ ] Other: _______________________________
4. DESCRIPTION OF PROBLEM
(Please explain what happened.)
__________________________________________
__________________________________________
__________________________________________
5. PREVIOUS ATTEMPTS TO SOLVE
5.1 Have you tried to solve this problem already?
[ ] Yes [ ] No
5.2 If yes, what was done and by whom?
______________________________________
______________________________________
6. DESIRED OUTCOME
(What result do you hope for?)
__________________________________________
__________________________________________
7. CONFIDENTIALITY
7.1 Do you want your name kept confidential
as much as possible?
[ ] Yes [ ] No
8. SIGNATURES
Person Reporting:
Name: _____________________________________
Signature: ______________ Date: ____/____/____
Received By (Staff / Manager):
Name: _____________________________________
Role: _____________________________________
Signature: ______________ Date: ____/____/____
9. INTERNAL USE (MANAGER / PANEL)
Short plan for next steps:
__________________________________________
__________________________________________
