THE HSWAGATA BUDDHA TOOTH RELIC PRESERVATION MUSEUM
FOR INTERNAL USE ONLY
Template No.: T170
Template Title: Internal Policy Compliance Self-Check Form (Department)
Related Research Case IDs / Cluster: _______________________________
Linked Templates / Policies: T155 (Policy Drafting Cover Sheet), T162 (SOP Cover Sheet), T163 (Risk Register Entry), T164 (Workplan & Budget Summary), T153 (Board Minutes)
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 [ ]
1) Purpose (why we use this form)
This form helps each department check if it follows internal policies.
It records evidence and actions to fix gaps.
2) Self-check details
Department / Unit: __________________________________________
Period covered (month/quarter/year): __________________________
Self-check date: ____ / ____ / ______
Self-check team (names/roles): _______________________________
Supervisor / reviewer (name/role): ___________________________
3) Rating guide (choose one per policy)
Compliant (C) = we follow it fully, and we have evidence.
Partly compliant (P) = we follow some parts, but gaps exist.
Not compliant (N) = we do not follow it, or we have no evidence.
Not applicable (NA) = this policy does not apply to our work.
Compliance rating: C [ ] P [ ] N [ ] NA [ ]
4) Policy list for this department (main checklist)
Use one block per policy. Add more blocks as needed.
Policy check #1
Policy title: ______________________________________________
Policy code / version (if known): ___________________________
Applies to this department? Yes [ ] No [ ] (If No, mark NA and explain)
Compliance rating (tick one): C [ ] P [ ] N [ ] NA [ ]
Evidence available (tick and describe):
SOP exists and used [ ] SOP code: __________________________
Staff briefing/training record [ ] Date: //____
Logbook/register entry [ ] Which: __________________________
Reports/minutes show compliance [ ] Which: __________________
Photos/labels/signage [ ] Where: ____________________________
Other evidence: __________________________ [ ]
Evidence location (cabinet/folder + digital path): ______________________
Gaps found (if any):
Actions required (if rating is P or N):
Action 1: _________________________________________________
Owner (name/role): ____________________ Deadline: //____
Evidence to provide after fix: ______________________________
Action 2 (optional): ________________________________________
Owner: ____________________ Deadline: //____
Policy check #2
Policy title: ______________________________________________
Policy code / version: _____________________________________
Applies? Yes [ ] No [ ]
Rating: C [ ] P [ ] N [ ] NA [ ]
Evidence (short): _________________________________________________
Evidence location: ________________________________________________
Gaps (short): _____________________________________________________
Action(s): ________________________________________________________
Owner: __________________________ Deadline: //____
(Add more policy checks as needed.)
5) Summary results (quick view)
Total policies checked: ______
C (Compliant): ______
P (Partly compliant): ______
N (Not compliant): ______
NA (Not applicable): ______
Top 3 issues to fix first (priority):
6) Action plan register (all actions in one place)
Use one line per action so it is easy to track.
Action #1
Related policy: ______________________________
Task: _______________________________________
Owner: ___________________________
Deadline: ____ / ____ / ______
Priority: High [ ] Medium [ ] Low [ ]
Evidence to file: ____________________________
Status: Open [ ] In progress [ ] Done [ ]
Action #2
Related policy: ______________________________
Task: _______________________________________
Owner: ___________________________
Deadline: ____ / ____ / ______
Priority: High [ ] Medium [ ] Low [ ]
Status: Open [ ] In progress [ ] Done [ ]
(Add more as needed.)
7) Risk and escalation (when to report higher)
Tick if any apply. If “Yes”, also consider a T163 risk entry.
Any gap affects relic access, custody, security, or Sacred-Restricted details.
Yes [ ] No [ ] Notes: __________________________________________Any gap may cause harm to visitors, staff, or community trust.
Yes [ ] No [ ] Notes: __________________________________________Any legal/registration requirement may be breached.
Yes [ ] No [ ] Notes: __________________________________________Any repeated non-compliance from last review.
Yes [ ] No [ ] Notes: __________________________________________
Escalate to (tick): Director [ ] Board [ ] Security head [ ] Conservation head [ ] Legal/Compliance [ ]
Escalation date (if done): ____ / ____ / ______
8) Review schedule (next self-check)
Review cycle (tick): Monthly [ ] Quarterly [ ] Every 6 months [ ] Yearly [ ] After incident [ ]
Next planned self-check date: ____ / ____ / ______
Person responsible to schedule: ______________________________
9) Sign-off and filing
Prepared by (name/role): _______________________ Signature: __________ Date: //____
Reviewed by (Unit Head): _______________________ Signature: __________ Date: //____
Reviewed by (Director/Governance, if needed): ___ Signature: __________ Date: //____
File location (cabinet/folder + digital path): __________________________
Form version / code: ____________________ Effective date: //____
