THE HSWAGATA BUDDHA TOOTH RELIC PRESERVATION MUSEUM
FOR INTERNAL USE ONLY
Template No.: T248
Template Title: Duty of Care / Staff Wellbeing Follow-up (After Conflict / Threat / Incident)
Related Research Case IDs / Cluster: Cluster F – HGT Conflicts & Security (Cases 66–85)
Linked Templates / Policies: T241 (Threat Report), T236 (Security Incident), T232 (Risk Sheet), T231 (Actions Tracker), T246 (Confidentiality Decision)
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 [ ]
A) Purpose (simple)
Purpose: to check staff safety and wellbeing after a conflict, threat, or security case. This is support, not blame.
B) Link to incident/case
Linked Case ID: ___________________________
Linked form(s): T241 ID: __________ T236 ID: __________ T244 ID: __________ (if any)
Date of incident period: From //____ to //____
C) Staff member details (use code if needed)
Staff code / name: ___________________________
Role: ___________________________ Department: ______________________
Work location (general): ______________________
Preferred contact method: Phone [ ] Email [ ] In-person [ ] Other: ______
D) Immediate safety check
Is the staff member safe now? Yes [ ] No [ ] Unsure [ ]
If No/Unsure, actions taken now (tick):
Inform Security Lead [ ]
Adjust duty / remove from front-line today [ ]
Arrange safe transport home (if needed) [ ]
Contact authorities/emergency services (as required) [ ]
Other: ________________________________________
E) Wellbeing check-in (last 7 days)
Tick any that apply (staff may choose not to answer):
Trouble sleeping [ ]
High stress or fear at work [ ]
Difficulty concentrating [ ]
Avoiding certain areas/tasks [ ]
Feeling unsafe due to messages/people [ ]
Online harassment pressure [ ]
Conflict with community/stakeholders affecting work [ ]
Other (optional): _______________________________
Short notes (staff words, 3–6 lines):
F) Work impact (practical)
Did this affect work duties? Yes [ ] No [ ]
If Yes, tick what changed:
Missed shifts [ ]
Reduced performance [ ]
Need change of role/position [ ]
Need extra supervision [ ]
Need time off [ ]
Other: ________________________________________
G) Support provided by HSWAGATA
Tick support options given:
Private check-in meeting held [ ] Date: //____
Supervisor support plan agreed [ ]
Temporary duty change (non-front-line) [ ]
Extra security support at workplace [ ]
Help to document harassment/threat evidence (T229/T241) [ ]
Communication protection (spokesperson rule, no direct contact) [ ]
Breaks and workload adjustment [ ]
Other: ________________________________________
Support notes (simple):
H) Referral and external support (if needed)
Did staff request professional support? Yes [ ] No [ ]
If Yes, tick:
Counsellor/mental health support [ ] Medical support [ ] Legal advice [ ] Other: ______
Referral arranged by (role): ___________________ Date: //____
Note: Keep privacy. Share only what is needed.
I) Risk update and protection steps
Does this case increase risk to staff or site? Yes [ ] No [ ] Unsure [ ]
If Yes/Unsure, update:
T232 Risk Sheet updated [ ] Date: //____
Access controls / visitor controls adjusted (T234/T235/T240) [ ]
Threat monitoring plan active (T241) [ ]
J) Follow-up plan (dates + owner)
Next check-in date 1: //____ Owner (role): __________________
Next check-in date 2: //____ Owner (role): __________________
Next check-in date 3: //____ Owner (role): __________________
Actions to add to T231 (if needed):
_______________________ Owner: __________ Due: //____
_______________________ Owner: __________ Due: //____
K) Confidentiality and file handling
Access level for this wellbeing record:
Internal [ ] Restricted [ ] Sacred-Restricted [ ]
Stored at (cabinet/folder label): ______________________________________
Allowed roles (write): ________________________________________________
L) Closure
Status: Open [ ] Monitoring [ ] Closed [ ]
Closure date (if closed): //______
Closure note (2–4 lines):
M) Sign-off
Prepared by (Name): _________________________ Role: ___________________
Signature: _________________________________ Date: //______
Staff acknowledgement (optional): __________________ Signature: ________ Date: //______
Reviewed by Supervisor/Head: _____________________ Signature: _________ Date: //______
