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
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.
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:
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: _______________________________________________________
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):
D) Who is involved (if named)
(Write names/roles if you know them. If not, describe.)
Person(s) involved / witnessed:
Name/role/description: _____________________________________
Name/role/description: _____________________________________
Name/role/description: _____________________________________
Is anyone in a leadership role involved? Yes [ ] No [ ] Unsure [ ]
Are external people involved (partners/contractors)? Yes [ ] No [ ] If yes: _____________
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): ______________________________________
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: _______________________________________________________
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): __________________________
Have you tried to solve it informally? Yes [ ] No [ ]
If yes, what happened (short): __________________________________
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):
I) What outcome do you want? (optional)
Investigation [ ] Mediation [ ] Policy fix [ ] Training [ ] Financial audit [ ] Security upgrade [ ] Other: ______
Notes: ________________________________________________________
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: ____ / ____ / ______
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): __________________________________________
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: ____ / ____ / ______