SMH-Venice Star/CareGram Submission Form

Your Name*

(Person filling out the form)

Your relationship to the person you are recognizing*

(Person filling out the form's status)

Employee

Patient

Family Member

Employee's Name*

Please enter First & Last Name if known.

Department of Care*

Department where care was provided.

Room Number

Reason for Employee Star/CareGram*

Please write why this employee is receiving a Star/CareGram. They will receive a copy of this for encouragement and recognition!

Send me a copy of my responses