THE HSWAGATA BUDDHA TOOTH RELIC PRESERVATION MUSEUM
FOR INTERNAL USE ONLY
Template No.: T136
Template Title: Wellbeing & Burnout Check-In Form
Related Research Case IDs / Cluster: Cluster B – Non-Human Guardians & Vocation (Cases 11–20)
Linked Templates / Policies: T126–T135, Duty of Care & Wellbeing Guidelines, Security & Access Policy, Institutional Policies for Relic Stewardship
Date of form: ____ / ____ / ______
Prepared by / Role: _________________________________
Office / Unit: _______________________________________
Country / Location: _________________________________
Confidentiality Level:
Internal only [ ] Restricted [ ] Sacred-Restricted / Sensitive [ ]
Use of this form (tick):
New case / action [ ] Follow-up [ ] Annual review [ ] Archive only [ ]
SECTION 1 – PERSON & CONTEXT
1.1 Person checked-in
-
Full name: _________________________________________
-
Dharma / monastic name (if any): ____________________
-
Status (tick):
[ ] Bhikkhu / Monk [ ] Bhikkhunī / Nun
[ ] Novice [ ] Lay male
[ ] Lay female [ ] Other: __________________ -
Main role in HSWAGATA (tick all that apply):
[ ] Core Relic Custodian
[ ] Assistant Custodian
[ ] Trainee Custodian
[ ] Security / guard
[ ] Guide / educator
[ ] Museum / admin staff
[ ] Volunteer
[ ] Other: ________________________________________
1.2 Check-in setting
This form is filled as (tick):
[ ] Self-check (private, may be shared later)
[ ] Joint check with mentor (T133)
[ ] Supervisor / duty of care meeting
[ ] Return-to-duty check
[ ] Other: _________________________________________
Place of meeting (if joint): __________________________
Date of meeting: ____ / ____ / ______
SECTION 2 – STRESS, ENERGY & MOOD
Goal: simple picture of how you feel now and in recent weeks.
2.1 Stress level (last 2–4 weeks)
On a scale from 0 to 10, where
0 = no stress at all,
5 = medium stress,
10 = very strong stress most of the time,
My stress level is: 0 1 2 3 4 5 6 7 8 9 10
Circle or tick one number.
Short comment (optional):
2.2 Tiredness / energy
In the last 2–4 weeks, I feel:
-
In my body:
[ ] Mostly fresh and strong
[ ] Often a bit tired
[ ] Often very tired or low energy
[ ] Exhausted / close to burnout -
In my mind:
[ ] Clear and steady
[ ] Sometimes foggy or distracted
[ ] Often overloaded / cannot think clearly
[ ] Very heavy or close to shutting down
Short comment:
2.3 Mood pattern
Most days in this period, I felt (tick all that fit):
[ ] Calm or content
[ ] Interested and motivated
[ ] Often tense or worried
[ ] Often irritated or angry
[ ] Often sad or flat
[ ] Feeling numb / “on auto-pilot”
[ ] Up and down a lot
[ ] Other: __________________________________________
Is there anything that worries you about your mood right now?
[ ] No
[ ] A little
[ ] A lot – I want to talk more about it
Short note (if you wish):
SECTION 3 – WORKLOAD & BALANCE
Goal: see if duties are reasonable and safe over time.
3.1 Workload in last 2–4 weeks
Hours per week on HSWAGATA duties (approx.): ______
How does this feel for you?
[ ] Light
[ ] Reasonable / ok
[ ] Heavy
[ ] Too heavy
Type of work (tick main ones):
[ ] Shrine / guardianship duty
[ ] Night vigils / late shifts
[ ] Administration / office work
[ ] Teaching / guiding visitors
[ ] Security and practical tasks
[ ] Travel / events
[ ] Other: __________________________________________
3.2 Signs of strain
In the last month, have you noticed (tick any):
[ ] Hard to sleep or poor sleep
[ ] Headaches or body pains more than usual
[ ] Hard to focus or remember things
[ ] More conflict or sharp words with others
[ ] Loss of joy in duties that I used to enjoy
[ ] Wanting to avoid relic areas or people
[ ] Thinking “I cannot keep going like this”
[ ] None of these
Short example (if safe to share):
3.3 Work–rest balance
-
Days off in the last month: ______
I feel my balance of work, rest, and personal practice is:
[ ] Good
[ ] Almost good, needs small changes
[ ] Not good, needs clear change
[ ] Very poor / may not be safe to continue like this
Short note:
SECTION 4 – SUPPORT & RESOURCES
4.1 Current support
At present, I feel:
[ ] Well supported
[ ] Some support, but not enough
[ ] Quite alone with my problems
Who supports you now? (tick all that apply)
[ ] Mentor (T133)
[ ] Spiritual teacher / preceptor
[ ] Other custodians / colleagues
[ ] Family
[ ] Friends
[ ] Counsellor / therapist
[ ] Doctor / health worker
[ ] Other: __________________________________________
[ ] No one / I rarely share my worries
4.2 Ease of asking for help
Right now, asking for help feels:
[ ] Easy – I can talk openly
[ ] A bit difficult
[ ] Very hard – I fear burdening or upsetting others
Short note:
4.3 What kind of support would help you now?
Tick as many as you wish:
[ ] A talk with my mentor
[ ] A talk with a spiritual teacher
[ ] A talk with a wellbeing / duty of care officer
[ ] Medical / health check
[ ] Counselling or mental health support
[ ] Retreat or quiet days
[ ] Lighter duties for a time
[ ] Clearer guidance on my role
[ ] Training (time management, conflict handling, etc.)
[ ] Other: __________________________________________
Which is your top 1–2 support wishes?
SECTION 5 – AGREED ACTIONS (PLAN TO REDUCE STRESS / BURNOUT RISK)
To be filled together if used in a meeting. If self-check only, you may still write a simple plan for yourself.
5.1 Immediate actions (next 1–4 weeks)
We agree to take these small, clear steps:
Action 1:
Who will do this? __________________ By when? _________
Action 2:
Who will do this? __________________ By when? _________
Optional Action 3:
5.2 Medium-term actions (next 3–6 months)
[ ] Review workload and adjust duties if needed
[ ] Plan rest / retreat time
[ ] Set regular meetings with mentor (T133)
[ ] Arrange health / counselling support
[ ] Give training (e.g. handling conflict, time use)
[ ] Other: __________________________________________
Short note on medium-term plan:
5.3 Changes to relic-related duties
Do we need to change relic duties at this time for safety and wellbeing?
[ ] No change needed
[ ] Small change (e.g. fewer night shifts, more help)
[ ] Temporary reduction of duties
[ ] Temporary pause from relic guardianship
[ ] Other: __________________________________________
If change is planned, write details and time frame:
SECTION 6 – SAFETY & ESCALATION (IF NEEDED)
Use this section if stress or burnout feels very serious.
6.1 Current risk level (joint view)
Together, we feel the situation is:
[ ] Mild – normal stress, can be managed with simple steps
[ ] Moderate – needs clear plan and follow-up
[ ] Serious – risk of burnout or harm if nothing changes
[ ] Very serious – urgent help needed
Short explanation:
6.2 Extra steps if serious
If marked “Serious” or “Very serious”, tick any steps to take:
[ ] Inform wellbeing / duty of care officer
[ ] Inform supervisor / senior custodian
[ ] Refer to professional health service
[ ] Reduce or pause high-pressure duties
[ ] Arrange close follow-up meetings
[ ] Other: __________________________________________
SECTION 7 – SIGNATURES & NEXT REVIEW
7.1 Person checked-in
I have shared honestly as best I can.
I understand that this form is used to help protect my wellbeing and safe relic guardianship.
Name (print): ________________________________________
Signature: ___________________________ Date: ____ / ____ / ______
7.2 Mentor / reviewer (if involved)
Name: _______________________________________________
Role: _______________________________________________
I will do my best to support the agreed actions, within my role and in line with HSWAGATA policies.
Signature: ___________________________ Date: ____ / ____ / ______
7.3 Next check-in date
Suggested next wellbeing check-in:
Date: ____ / ____ / ______
Type:
[ ] Short check by mentor
[ ] Duty of care meeting
[ ] Annual review
[ ] Other: _____________________________
SECTION 8 – ARCHIVING & LINKS
8.1 File storage
-
Physical file code / folder: _________________________
-
Digital archive path / ID: __________________________
8.2 Linked records
[ ] T133 – Mentor–Mentee Assignment Form
[ ] T134 – Individual Practice & Precepts Review Sheet
[ ] T132 – Spiritual Emergency / Disturbance Incident Log (if any)
[ ] Duty of care / wellbeing plan (code: __________)
[ ] HR / staff file reference: ________________________
[ ] Other: ___________________________________________
