DUTY OF CARE & WELL-BEING CHECK FORM Form Code: HSW-F42
HSWAGATA BUDDHA TOOTH RELICS PRESERVATION MUSEUM
DUTY OF CARE & WELL-BEING CHECK FORM
Form Code: HSW-F42
Date of Check: ____ / ____ / ______
1. PERSON DETAILS
1.1 Name: __________________________________________
1.2 Role:
[ ] Staff [ ] Volunteer
1.3 Department / Unit: ____________________________
2. MAIN STRESS FACTORS
(tick all that apply; can add short notes)
[ ] Heavy workload
Notes: ________________________________________
[ ] Conflict with colleagues or visitors
Notes: ________________________________________
[ ] Online attacks / negative messages
Notes: ________________________________________
[ ] Difficult case (complaint, dispute, etc.)
Notes: ________________________________________
[ ] Personal / family stress (optional to share)
Notes: ________________________________________
[ ] Other: ________________________________________
3. PHYSICAL HEALTH (OPTIONAL)
3.1 Any health concerns linked to work?
[ ] Yes [ ] No
If yes, short note:
_____________________________________________
4. MENTAL / EMOTIONAL WELL-BEING (OPTIONAL)
4.1 Feelings at work (tick any that fit):
[ ] Calm / fine
[ ] Often tired
[ ] Often worried
[ ] Often sad or low
[ ] Often angry
[ ] Other: ________________________________
4.2 Would you like support?
[ ] Yes [ ] No [ ] Not sure
5. SUPPORT OFFERED
(To be filled by supervisor / support person.)
[ ] Change of duty or schedule
[ ] Short rest / leave
[ ] Private talk / mentoring
[ ] Referral to counselling / health services
[ ] Extra training / help with tasks
[ ] Other: _________________________________
Details:
____________________________________________
____________________________________________
6. FOLLOW-UP
6.1 Follow-up date (if needed):
____ / ____ / ______
6.2 Notes from follow-up (later):
_________________________________________
7. SIGNATURES
Person Checked:
Name: ______________________________________
Signature (optional): _______ Date: ____/____/____
Supervisor / Support Person:
Name: ______________________________________
Role: ______________________________________
Signature: _____________ Date: ____/____/____