THE HSWAGATA BUDDHA TOOTH RELIC PRESERVATION MUSEUM
FOR INTERNAL USE ONLY
Template No.: T201
Template Title: Relic Sample Request & Justification Form
Related Research Case IDs / Cluster: Cluster E (Science, Testing, Misinformation)
Linked Templates / Policies: T202 Lab Pre-Screening, T203 Data Governance, T204 Chain-of-Custody, T205 Transport, Relic Stewardship Policy
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
FIELDS (complete all)
1) Relic ID and Basic Details
Relic ID: ______________________________
Relic name / type (if used): ______________________________
Current location (building/room/cabinet): ______________________________
Current custodian / responsible officer: ______________________________
Current condition (short note): ______________________________________
Photos taken today? Yes [ ] No [ ] File name(s): ______________________
2) Purpose (Why request a sample?)
Main purpose (tick):
Conservation / material care [ ]
Authenticity support (limited claim) [ ]
Misinformation response [ ]
Research / education [ ]
Other: __________________________
Question(s) we want to answer (1–3 lines):
How the result will help HSWAGATA (short):
3) Proposed Methods (What will be done?)
Proposed sampling type: Micro-sample [ ] Swab [ ] Dust/residue only [ ] Other: ________
Proposed method(s)/test(s) after sampling (list):
Estimated sample size (smallest possible): ______________________________
Sample location on relic (describe clearly; attach sketch/photo if possible):
Who will collect the sample (name/role): ______________________________
Proposed lab/partner (if known): ______________________________________
4) Alternatives Tried First (Non-sample options)
Tick what has already been tried (attach evidence if possible):
Visual check + photo record [ ]
Condition report by conservator [ ]
Non-contact imaging (macro / 3D) [ ]
Non-destructive tests (no sampling) [ ]
Expert review panel [ ]
Other: ______________________________
Result summary (why these were not enough):
5) Risk Summary (Simple and honest)
Rate each risk: Low [ ] Medium [ ] High [ ]
Physical risk to relic (damage/contamination): Low [ ] Med [ ] High [ ]
Security risk (movement/theft): Low [ ] Med [ ] High [ ]
Faith/community sensitivity risk: Low [ ] Med [ ] High [ ]
Reputation/media risk: Low [ ] Med [ ] High [ ]
Legal/customs risk (if cross-border): Low [ ] Med [ ] High [ ]
Risk notes (2–5 lines):
6) Risk Controls (How we reduce risk)
Tick all that will be used:
Smallest possible sample [ ]
Clean tools + contamination control [ ]
Two-person rule during sampling [ ]
Secure area + limited access [ ]
Chain-of-custody log will be used (T204) [ ]
Packaging/transport checklist will be used (T205) [ ]
Data governance summary will be prepared (T203) [ ]
Communication plan ready if needed (T208) [ ]
Other controls: _______________________________________________
7) Decision Request
Requested decision (tick):
Approve sample request [ ]
Approve with conditions [ ] (write conditions): __________________________
Do not approve [ ] (reason): __________________________________________
8) Approvals (sign before any sampling)
Head, Scientific Verification & Education: __________________ Date: //____
Head, Conservation & Maintenance: __________________________ Date: //____
Head, Conflict Resolution & Security: _______________________ Date: //____
Board / Director approval (as required): _____________________ Date: //____
9) Attachments Checklist
Photos / condition note [ ]
Sketch or marked photo of sampling location [ ]
Evidence of alternatives tried [ ]
Proposed lab info (if known) [ ]
Draft chain-of-custody plan (T204) [ ]
Draft packaging/transport plan (T205) [ ]
