DUTY OF CARE & WELL-BEING CHECK FORM Form Code: HSW-F42

 HSWAGATA BUDDHA TOOTH RELICS PRESERVATION MUSEUM

DUTY OF CARE & WELL-BEING CHECK FORM

Form Code: HSW-F42

Date of Check: ____ / ____ / ______

1. PERSON DETAILS

   1.1 Name: __________________________________________

   1.2 Role:

       [ ] Staff   [ ] Volunteer

   1.3 Department / Unit: ____________________________

2. MAIN STRESS FACTORS

   (tick all that apply; can add short notes)

   [ ] Heavy workload

       Notes: ________________________________________

   [ ] Conflict with colleagues or visitors

       Notes: ________________________________________

   [ ] Online attacks / negative messages

       Notes: ________________________________________

   [ ] Difficult case (complaint, dispute, etc.)

       Notes: ________________________________________

   [ ] Personal / family stress (optional to share)

       Notes: ________________________________________

   [ ] Other: ________________________________________

3. PHYSICAL HEALTH (OPTIONAL)

   3.1 Any health concerns linked to work?

       [ ] Yes   [ ] No

       If yes, short note:

       _____________________________________________

4. MENTAL / EMOTIONAL WELL-BEING (OPTIONAL)

   4.1 Feelings at work (tick any that fit):

       [ ] Calm / fine

       [ ] Often tired

       [ ] Often worried

       [ ] Often sad or low

       [ ] Often angry

       [ ] Other: ________________________________

   4.2 Would you like support?

       [ ] Yes   [ ] No   [ ] Not sure

5. SUPPORT OFFERED

   (To be filled by supervisor / support person.)

   [ ] Change of duty or schedule

   [ ] Short rest / leave

   [ ] Private talk / mentoring

   [ ] Referral to counselling / health services

   [ ] Extra training / help with tasks

   [ ] Other: _________________________________

   Details:

   ____________________________________________

   ____________________________________________

6. FOLLOW-UP

   6.1 Follow-up date (if needed):

       ____ / ____ / ______

   6.2 Notes from follow-up (later):

       _________________________________________

7. SIGNATURES

   Person Checked:

   Name: ______________________________________

   Signature (optional): _______ Date: ____/____/____

   Supervisor / Support Person:

   Name: ______________________________________

   Role: ______________________________________

   Signature: _____________ Date: ____/____/____