Template No.: T285 Template Title: Whistleblowing & Concern Reporting Form

 THE HSWAGATA BUDDHA TOOTH RELIC PRESERVATION MUSEUM

FOR INTERNAL USE ONLY

Template No.: T285

Template Title: Whistleblowing & Concern Reporting Form

Related Research Case IDs / Cluster: _______

Linked Templates / Policies: _______________

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

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T285 – Whistleblowing & Concern Reporting Form

Purpose:
This form is a safe way to report concerns about wrongdoing or harm. You can report even if you are not 100% sure. Report in good faith.

Important safeguards (read and tick):

• I understand HSWAGATA does not allow retaliation against people who report in good faith. [ ]

• I understand this report will be handled as confidential as possible. [ ]

• I understand false reports made on purpose may lead to action. [ ]

Can I report anonymously? Yes. If you stay anonymous, it may be harder to ask follow-up questions.

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A) Reporter details (optional, unless you want follow-up)

• I want to report: Named [ ] Anonymous [ ]

• Full name (optional): __________________________________________

• Role (tick): Staff [ ] Volunteer [ ] Monk/Nun [ ] Visitor [ ] Donor [ ] Partner [ ] Contractor [ ] Other: ______

• Department / unit (if any): _____________________________________

• Safe contact method (choose one): Email [ ] Phone [ ] Letter [ ] Other: ______

• Safe contact details: __________________________________________

• Best days/times to contact safely: _______________________________

If you fear risk from being contacted, write “DO NOT CONTACT” and give a safe method only:

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B) Type of concern (tick one or more)

• Theft / loss of relics or sacred items [ ]

• Damage / neglect / unsafe conservation [ ]

• Fraud / misuse of money / bribery / corruption [ ]

• Abuse of power / unfair treatment [ ]

• Harassment / bullying / discrimination [ ]

• Safeguarding risk (child / vulnerable person) [ ]

• Security risk (break-in, unsafe access, threats) [ ]

• Conflict of interest / gifts / improper benefit [ ]

• Falsifying records / hiding incidents [ ]

• Other: _______________________________________________________

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C) Concern summary (issue)

Write what happened in simple facts (who, what, when, where).

• Date(s) of incident(s): ____ / ____ / ______ to ____ / ____ / ______

• Location(s): _________________________________________________

• What happened (brief):

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D) Who is involved (if named)

(Write names/roles if you know them. If not, describe.)

• Person(s) involved / witnessed:

  1. Name/role/description: _____________________________________

  2. Name/role/description: _____________________________________

  3. Name/role/description: _____________________________________

• Is anyone in a leadership role involved? Yes [ ] No [ ] Unsure [ ]

• Are external people involved (partners/contractors)? Yes [ ] No [ ] If yes: _____________

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E) Evidence and records

• Do you have evidence? Yes [ ] No [ ] Unsure [ ]
  If yes, tick what you have:
  Email [ ] Message/chat [ ] Photo [ ] Video [ ] Document [ ] Receipt [ ] Logbook entry [ ] Witness names [ ] Other: ______

• Where is the evidence kept? (device, folder, location) ____________________________

• Attachments provided with this report: Yes [ ] No [ ]
  List attachments (file name / description): ______________________________________

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F) Immediate risk check

Is there an urgent risk right now?

• Risk to relics / sacred objects: Yes [ ] No [ ]

• Risk to a person’s safety: Yes [ ] No [ ]

• Risk of evidence being destroyed: Yes [ ] No [ ]

If “Yes” to any, what urgent step do you request?
Stop access now [ ] Secure room [ ] Call security [ ] Call safeguarding lead [ ] Other: ______
Details: _______________________________________________________

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G) Steps already taken (steps taken)

• Have you reported this before? Yes [ ] No [ ]
  If yes:

• To whom (role/name): _________________________________________

• Date: ____ / ____ / ______

• What response did you receive (short): __________________________

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• Have you tried to solve it informally? Yes [ ] No [ ]
  If yes, what happened (short): __________________________________

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H) Protection requested (requested protection)

Tick what you need:

• Keep my identity confidential [ ]

• I want to stay anonymous [ ]

• No direct contact with the person(s) involved [ ]

• Change of duties / schedule (temporary) [ ]

• Safe meeting place [ ]

• Support person present in meetings [ ]

• Other protection needed: ______________________________________

Any special risk or fear you want us to know (optional, short):

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I) What outcome do you want? (optional)

Investigation [ ] Mediation [ ] Policy fix [ ] Training [ ] Financial audit [ ] Security upgrade [ ] Other: ______
Notes: ________________________________________________________

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J) Consent and declaration

Tick one:

• I agree HSWAGATA may use my information only for handling this concern. [ ]

• I prefer limited use of my information (explain): ________________________________

Declaration (tick):

• I believe the information in this report is true to the best of my knowledge. [ ]

Signature (if named report): ___________________________ Date: ____ / ____ / ______

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FOR OFFICE USE ONLY

K) Receipt and registration

• Date received: ____ / ____ / ______ Time: ______

• Received by (name/role): _______________________________________

• Case code / reference no.: ______________________________________

• Channel received: In person [ ] Email [ ] Phone [ ] Letter [ ] Box [ ] Other: ______

• Acknowledgement sent (if contact available): Yes [ ] No [ ] Date: //______

L) Triage (first review)

• Category confirmed: Ethics [ ] Safeguarding [ ] Finance [ ] Security [ ] Relic care [ ] HR [ ] Other: ______

• Urgency: Emergency (same day) [ ] Urgent (≤7 days) [ ] Routine [ ]

• Assigned lead officer/unit: ______________________________________

• Conflict of interest check done: Yes [ ] No [ ]
  If yes, mitigation (recusal/alternative lead): _______________________________

M) Actions log

Date	Action taken	Owner	Due date	Status	Notes / evidence

N) Decision and outcome

• Outcome (tick): Unfounded [ ] Partly founded [ ] Founded [ ] Referred [ ] Unable to assess [ ]

• Decision date: ____ / ____ / ______

• Actions completed (summary): __________________________________________

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• Reporter informed (if possible): Yes [ ] No [ ] Date: //______

• Case closed date: ____ / ____ / ______

• Archive location (file code/path): ______________________________________

Sign-off (Office):
Handled by: __________________________ Signature: ____________ Date: ____ / ____ / ______
Reviewed by (Ethics/Safeguarding chair or ED): __________________ Signature: ____________ Date: ____ / ____ / ______