Standing Ovation Form - For Multiple Recipients
This form is for multiple recipients only.

Multiple Recipients' Information
Today's Date: Was an employee, physician or volunteer with whom you had contact at Cedars-Sinai especially kind, caring, helpful, knowledgeable or responsive?

Please fill out this form so that our Executive Management can send out a special thank you letter along with your comments to this individual and his/her supervisor.

Any patient, visitor, family member, employee, physician or volunteer can use this form to recognize quality service.

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Please List: First & Last name, Title & Department of each person.
Example: John Doe MA II Pediatrics

Description of Service
Please describe specifically what this person did that demonstrated
a special spirit of caring or service:

Your Information
Are you a Patient or Employee?   Patient Employee
If you are a Patient, please fill out this section:
Inpatient  
  Room Number:
Outpatient  
  Service Attended:
Family Member  
Other:
If you are an Employee or Staff Member, please fill out this section:
Employee
  Department or Nursing Unit:
Physician
Volunteer

Your First Name:
Your Last Name:
E-Mail Address: (Optional)
Note: If you are a patient completing this form, your name will be cited in the certificate.
If you DO NOT want your name included, please check this box.