SMH 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!

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