Template No.: T189 Template Title: Community Needs & Ideas Survey Form
THE HSWAGATA BUDDHA TOOTH RELIC PRESERVATION MUSEUM
FOR INTERNAL USE ONLY
Template No.: T189
Template Title: Community Needs & Ideas Survey Form
Related Research Case IDs / Cluster: Cluster D (Everyday Faith & Lay Donations), Cases 36–45
Linked Templates / Policies: T183 (Community Feedback & Complaint), T180 (Community Event Proposal), T181 (Village Stupa Project Tracking), T188 (Leader/Elder Consultation Record), Data/Privacy Rules, T173 (Records Classification)
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 [ ]
1) Purpose (why we ask)
This survey asks what the community needs and wants.
It helps HSWAGATA plan education, welfare support, peace work, and local heritage care.
2) Survey details (for staff)
Survey location (village/area): ____________________________________
Survey method (tick): Paper [ ] Interview [ ] Group meeting [ ] Online [ ] Other: ____
Enumerator / interviewer (name/role): ______________________________
Language used: _________________________________________________
Number of people surveyed (if group): ________
3) About you (optional)
A) Do you want to stay anonymous? Yes [ ] No [ ]
If No, optional contact:
Name: ______________________________________________
Phone/email (optional): _______________________________
B) Your connection (tick):
Local resident [ ] Temple member [ ] Donor/supporter [ ] Student [ ] Teacher [ ] Community leader [ ] Visitor [ ] Other: ______
C) Age group (tick):
Under 18 [ ] 18–24 [ ] 25–39 [ ] 40–59 [ ] 60+ [ ] Prefer not to say [ ]
D) Consent to contact (tick):
Yes, you may contact me to clarify my answers. [ ]
No, please do not contact me. [ ]
4) Area of need (choose what matters most)
Tick up to 3 areas.
Education and learning (schools, talks, heritage) [ ]
Community welfare (health, support for vulnerable people) [ ]
Peace and harmony (conflict reduction, calm relations) [ ]
Youth development (skills, safe activities) [ ]
Women and family support [ ]
Local stupa care / cleaning / repair [ ]
Environment and cleanliness (waste, water, trees) [ ]
Visitor management / local tourism benefits [ ]
Truthful information (stop rumours/misinformation) [ ]
Other area: __________________________ [ ]
5) Priority ranking (what should come first?)
Write 1, 2, 3, 4, 5 (1 = highest priority).
Education and learning: ____
Community welfare: ____
Peace and harmony: ____
Youth development: ____
Local stupa care: ____
Cleanliness/environment: ____
Visitor/tourism support: ____
Other: ______________________ : ____
6) Needs and problems (tell us what is happening)
Answer in short words or sentences.
A) What is the biggest need in your community right now?
B) What causes this problem? (optional)
C) Who is most affected? (children, elders, families, etc.)
7) Ideas and suggestions (what should we do?)
A) Ideas for education (talks, school visits, learning materials):
B) Ideas for welfare support (safe, fair, and respectful):
C) Ideas for peace and harmony (reduce conflict, build trust):
D) Ideas for village stupa care (cleaning, repair, protection):
E) Any other idea:
8) Community strengths (what is already good?)
What is already working well in your community?
Who are good helpers/partners? (temples, schools, groups)
9) How you want to join (optional)
Would you like to help in any way? (tick)
Join a community meeting [ ]
Volunteer time (events/education/cleaning) [ ]
Share skills (teaching, building, IT, art, etc.) [ ]
Support a village stupa project [ ]
No, not now [ ]
If Yes, what can you do? ___________________________________________
10) Risks and sensitive notes (for staff)
Tick if any apply (do not write sensitive details here).
Risk of conflict between groups [ ]
Misinformation/rumours risk [ ]
Safety risk at events/visits [ ]
Sensitive relic/security topic mentioned [ ]
If any are ticked, consider: T183 [ ] T163 risk entry [ ] T188 consultation [ ]
11) Staff summary (to be completed by HSWAGATA)
Key needs heard (top 3):
Proposed next steps (what we will do next):
Follow-up needed? Yes [ ] No [ ]
If Yes, who/when: _________________________________________________
12) Record classification and filing
Recommended classification (T173): Public [ ] Internal [ ] Restricted [ ]
Reason (if Restricted): _____________________________________________
File code / reference ID: ____________________
File location (cabinet/folder + digital path): __________________________
Retention period: 1 year [ ] 3 years [ ] 5 years [ ] Other: ____
Prepared/collected by (name/role): __________________ Signature: __________ Date: //____
Reviewed by (Unit Head / Community Engagement): ______ Signature: __________ Date: //____