Template No.: T194 Template Title: Emergency Support to Community Case Record (Relief Action Record)
THE HSWAGATA BUDDHA TOOTH RELIC PRESERVATION MUSEUM
FOR INTERNAL USE ONLY
Template No.: T194
Template Title: Emergency Support to Community Case Record (Relief Action Record)
Related Research Case IDs / Cluster: Cluster D (Everyday Faith & Lay Donations), Cases 36–45 (add G if neglect/loss prevention systems apply; add H for learning model)
Linked Templates / Policies: T180 (Community Event Proposal), T189 (Community Needs Survey), T188 (Leader/Elder Consultation), T183 (Feedback/Complaint), T177 (Cash Donation Acceptance), T178 (In-Kind Acceptance), T163 (Risk Register Entry), T169 (Learning Workshop Note), T190 (Media Approval), 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 use this record)
This record documents emergency support given to a community (relief action).
It shows what happened, what help was provided, who was reached, and what we learned.
2) Emergency event summary (event)
Event type (tick): Flood [ ] Fire [ ] Storm [ ] Landslide [ ] Drought [ ] Disease outbreak [ ] Conflict displacement [ ] Other: ______
Event name (if used locally): ______________________________________
Date(s) of event: ____ / ____ / ______ to ____ / ____ / ______
Location (village/area/district): ___________________________________
Who first informed HSWAGATA (name/role): __________________________
Date HSWAGATA learned of the event: ____ / ____ / ______
Short summary (3–6 lines, facts only):
3) Needs identified (what people needed)
How needs were identified (tick):
Leader/elder consultation (T188) [ ] Survey (T189) [ ] Direct observation [ ] Partner report [ ] Other: ____
Top needs (tick all that apply):
Food [ ] Clean water [ ] Temporary shelter materials [ ] Clothing [ ] Hygiene items [ ] Medicine/basic health items [ ] School items [ ] Transport support [ ] Repair tools/materials [ ] Other: ______
Notes (short):
4) Decision and approvals (why we acted)
Decision date: ____ / ____ / ______
Decision authority (tick): Unit Head [ ] Director [ ] Board [ ] Other: ____
Reason for support (simple): ______________________________________
Any limits set (budget/time/area): _________________________________
Risk entry created (T163)? Yes [ ] No [ ] Risk ID: ________________
5) Partners and coordination
List who worked with us.
Partner 1: ______________________________________________
Type (tick): Temple [ ] Village group [ ] School [ ] Local state office [ ] NGO [ ] Donor group [ ] Other: ____
Contact person: ______________________ Phone/email: ______________
Role in the relief action: _________________________________________
Partner 2: ______________________________________________
Contact: ____________________________
Role: _________________________________________________
Coordination meeting held? Yes [ ] No [ ]
If Yes, date and notes: _____________________________________________
6) Support provided (help given)
A) What we provided (tick and describe)
Cash support (approved) [ ]
In-kind goods (food/water/items) [ ]
Transport/logistics support [ ]
Volunteer support (labour/help desk) [ ]
Temporary space/support at museum site (if approved) [ ]
Other: __________________________ [ ]
Detailed list (write quantities and dates):
Item/support: _______________________ Qty/amount: ______ Date: //____
Item/support: _______________________ Qty/amount: ______ Date: //____
Item/support: _______________________ Qty/amount: ______ Date: //____
B) Distribution method (how it was given)
Distribution place(s): _____________________________________________
Distribution dates: //____ to //____
Managed by (name/role): _________________________________________
Crowd control plan used? Yes [ ] No [ ]
Fairness note (how we avoided favouritism):
7) People reached (people reached)
Estimated households supported: ________
Estimated individuals supported: ________
Priority groups reached (tick): Children [ ] Elders [ ] Disabled [ ] Pregnant women [ ] Low-income families [ ] Other: ____
How numbers were counted (tick): List/register [ ] Partner report [ ] Estimate only [ ] Other: ____
List/register file reference (if any): ______________________________
8) Donations and resources used (transparency)
Did we use donations for this emergency action? Yes [ ] No [ ]
If Yes:
Cash donations used (T177 ref IDs): ________________________________
In-kind donations used (T178 ref IDs): ______________________________
Any gifts with conditions reviewed (T179)? Yes [ ] No [ ] Ref: ________
Budget summary (simple)
Currency: ______
Estimated cost: ____________________
Actual cost (if known): ____________________
Funding sources (tick): Museum budget [ ] Donors [ ] Partners [ ] Grant [ ] Other: ____
Finance evidence filed (tick): Receipts [ ] Bank proof [ ] Inventory list [ ] Other: ____
Evidence file location/path: _________________________________________
9) Safeguarding, dignity, and peace notes (required)
Tick and note.
Support was voluntary and not used to pressure people. Yes [ ] No [ ]
People were treated with respect (no shame, no rude speech). Yes [ ] No [ ]
No political party messages were used. Yes [ ] No [ ]
Conflict risk managed calmly (if any). Yes [ ] No [ ] Notes: ___________
Child safety considered (children stayed with adults / safe space). Yes [ ] No [ ]
Any serious complaint received (T183)? Yes [ ] No [ ] Ref: ___________
Sensitive/security note: Do not include sensitive details in public posts.
10) Media and public communication (optional)
Any public announcement/post made? Yes [ ] No [ ]
If Yes:
Approved with T190? Yes [ ] No [ ] Ref: __________________________
Photos used? Yes [ ] No [ ]
Consent considered (especially children/faces)? Yes [ ] No [ ]
Link/screenshot location (internal): __________________________________
11) Outcomes and follow-up
Immediate outcome (short):
Follow-up needs (next 1–3 months):
Need 1: ________________________________________________
Owner: ____________________ Deadline: //____Need 2: ________________________________________________
Owner: ____________________ Deadline: //____
Longer-term support linked (tick):
Community event plan (T180) [ ] Village project (T181) [ ] Survey (T189) [ ] Consultation (T188) [ ] Other: ____
12) Lessons learned (lessons)
List 3–7 lessons. Keep them practical.
Any reforms needed (policy/SOP/training)? Yes [ ] No [ ]
If Yes, link: T169 [ ] T162 [ ] T155 [ ] Other: ____
13) Signatures and filing
Prepared by (name/role): _______________________ Signature: __________ Date: //____
Reviewed by (Unit Head / Community Engagement): _ Signature: __________ Date: //____
Reviewed by (Finance, if funds used): ___________ Signature: __________ Date: //____
Approved by (Director/Authority): ______________ Signature: __________ Date: //____
File code / reference ID: ____________________
Classification recommended (T173): Public [ ] Internal [ ] Restricted [ ]
File location (cabinet/folder + digital path): __________________________
Retention period: 1 year [ ] 3 years [ ] 5 years [ ] 10 years [ ] Other: ____