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GHANA DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE 2003

GHANA STATISTICAL SERVICE

IDENTIFICATION

LOCALITY NAME _______________
NAME OF HOUSEHOLD HEAD ______________
EA NUMBER _______
HOUSEHOLD NUMBER _____
REGION ____
DISTRICT ____

URBAN/RURAL ___

URBAN 1
RURAL 2

CITY/LARGE TOWN/SMALL TOWN/VILLAGE ___

CITY 1
LARGE TOWN 2
SMALL TOWN 3
VILLAGE 4

INTERVIEWER VISIT 1
DATE ___
INTERVIEWER'S NAME ____
RESULT* ___

NEXT VISIT:
DATE____
TIME ____

INTERVIEWER VISITS 2
DATE ___
INTERVIEWER'S NAME ___
RESULT* ____

NEXT VISIT:
DATE____
TIME____

INTERVIEWER VISITS 3
DATE ___
INTERVIEWER'S NAME ___
RESULT* ____

FINAL VISIT
DAY __
MONTH__
YEAR 200__
NAME___
RESULT___

TOTAL NO. OF VISITS___

TOTAL PERSONS IN HOUSEHOLD___

TOTAL ELIGIBLE WOMEN ___

TOTAL ELIGIBLE MEN____

LINE NO. OF RESP TO HH QUESTION

RESULT __
*RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _________

LANGUAGE OF QUESTIONNAIRE: ENGLISH

LANGUAGE OF INTERVIEW***: ___

LANGUAGE OF RESPONDENT*** ___

TRANSLATOR USED:

YES 1
NO 2

***LANGUAGE CODES:

ENGLISH 1
AKAN 2
GA 3
EWE 4
NZEMA 5
DAGBANI 6
OTHER (SPECIFY) 7

SUPERVISOR
NAME _______
DATE _______

FIELD EDITOR
NAME ______
DATE ______

OFFICE EDITOR
_____

KEYED BY
_____

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

1. LINE NO.

2. USUAL RESIDENTS AND VISITORS
Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

3. RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?*

* CODES FOR Q.3
RELATIONSHIP TO HEAD OF HOUSEHOLD:

01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CO-WIFE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 NOT RELATED
98 DON'T KNOW

4. SEX Is (NAME) male or female?

MALE 1
FEMALE 2

RESIDENCE

5. Does (NAME) usually live here?

YES 1
NO 2

6. Did (NAME) stay here last night?

YES 1
NO 2

7. AGE How old is (NAME)?

IN YEARS__

ELIGIBILITY

8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

9. CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6
.

9A. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59. IF HOUSEHOLD NOT SELECTED FOR MAN'S SURVEY, LEAVE BLANK.

PARENTAL SURVIVORSHIP AND RESIDENCE

FOR PERSONS LESS THAN 18 YEARS OLD**

10. Is (NAME)'s biological mother alive?

YES 1
NO 2
DK 8

11. (IF ALIVE) Does (NAME)'s biological mother live in this household? IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

_____

12. Is (NAME)'s biological father alive?

YES 1
NO 2
DK 8

13, (IF ALIVE) Does (NAME)'s biological father live in this household? IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

_____

EDUCATION

IF AGE 5 YEARS OR OLDER

14. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

15. What is the highest level of school (NAME) has attended?*** What is the highest grade (NAME) completed at that level?*** (15)

LEVEL___
GRADE___

IF AGE 5-24 YEARS

16. Is (NAME) currently attending school?

YES 1 (GO TO 18)
NO 2

17. During the current school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 19)

18. During the current school year, what level and grade [is/was] (NAME) attending?***

LEVEL___
GRADE___

19. During the previous school year, did (NAME) attend school at any time?

YES 1
NO 2 (NEXT LINE)

20. During that school year, what level and grade did (NAME) attend?***

LEVEL___
GRADE____

** Q.10 THROUGH Q.13
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q.11 AND Q.13, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

***CODES FOR Qs.15, 18 AND 20
EDUCATION LEVEL:

1 PRIMARY
2 MIDDLE/JSS
3 SECONDARY/SSS
4 HIGHER
8 DON'T KNOW

EDUCATION GRADE:

00 LESS THAN 1 YEAR COMPLETED (FOR Q.15 ONLY. THIS CODE IS NOT ALLOWED FOR Q.18 AND Q.20
98 DON'T KNOW

TICK HERE IF CONTINUATION SHEET USED___

Just to make sure that I have a complete listing:

1) Are there any other persons such as small children or infants that we have not listed?

YES__ (ENTER IN EACH TABLE)
NO__

2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?

YES__ (ENTER IN EACH TABLE)
NO__

3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

YES__(ENTER IN EACH TABLE)
NO__

21. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 22A)
PIPED INTO YARD/PLOT 12 (GO TO 22A)
PUBLIC TAP 13 (GO TO 22A)
WATER FROM OPEN WELL
OPEN IN DWELLING 21 (GO TO 22A)
OPENWELL IN YARD/PLOT 22 (GO TO 22A)
OPEN PUBLIC WELL 23
WATER FROM COVERED WELL OR BOREHOLE
PROTECTED WELL IN DWELLING 31 (GO TO 22A)
PROTECTED WELL IN YARD/PLOT 32 (GO TO 22A)
PROTECTED PUBLIC WELL 33
SURFACE WATER
SPRING 41
RIVER/STREAM 42
POND/LAKE 43
DAM 44
RAINWATER 51 (GO TO 22A)
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 22A)
SATCHEL WATER 81 (GO TO 22A)
OTHER (SPECIFY) ____ 96

22. How long does it take you to go there, get water, and come back?

MINUTES__
ON PREMISES 996

22A. In the last two weeks, how frequently has water been available from this source?

ALL THE TIME 1
SEVERAL HOURS EVERY DAY 2
A FEW TIMES A WEEK 3
LESS FREQUENTLY 4
NOT AT ALL 5
DON'T KNOW 8

22B. How does this household primarily dispose of household waste?

COLLECTED BY GOVERNMENT 01
COLLECTED BY COMMUNITY ASSOCIATION 02
COLLECTED BY PRIVATE COMPANY 03
DUMPED IN COMPUND 04
DUMPED IN STREET/EMPTY PLOT 05
BURNED 06
BURIED 07
COMPOSTED 08
RECYCLED 09
FED TO ANIMALS 10
OTHER (SPECIFY) ____ 96

23. What kind of toilet facilities does your household have?

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP LATRINE) 22
BUCKET/PAN 23
NO FACILITY/BUSH/FIELD/BEACH 31 (GO TO 25)
OTHER (SPECIFY) ____ 96

24. Do you share these facilities with other households?

YES 1
NO 2 (GO TO 25)

24A. How many households do you share these facilities with?

1-2 1
3-4 2
5-9 3
10+ 4

25. Does your household have:

Electricity?
A radio?
A television?
A video deck?
A telephone?
A refrigerator?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
VIDEO DECK
YES 1
NO 2
TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2

26. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
COAL, LIGNITE 05
CHARCOAL 06
FIREWOOD, STRAW 07
DUNG 08
OTHER (SPECIFY) ____ 96

26A. How likely is it that you could be evicted from this dwelling: Would you say very likely, somewhat likely, not at all likely?

VERY LIKELY 1
SOMEWHAT LIKELY 2
NOT AT ALL 3
DON'T KNOW 4

27. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND/MUD 11
MUD MIXED WITH DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
LINOLEUM 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
TERRAZZO 36
OTHER (SPECIFY) ___ 96

28. Does any member of your household own:

A bicycle?
A motorcycle or motor scooter?
A car or truck?
A tractor?
A horse/cart?

BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
TRACTOR
YES 1
NO 2
HORSE/CART
YES 1
NO 2

29. Does your household have any mosquito bed nets that can be used while sleeping?

YES 1
NO 2 (GO TO 32F)

29A. How many mosquito bed nets does your household have?

NUMBER ___

29B. When do you use the nets?

ALL YEAR ROUND 1
DURING THE RAINY SEASON 2
OTHER (SPECIFY)____ 6

30. ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. INFORMATION IS COLLECTED FOR EACH NET.

OBSERVED 1
NOT OBSERVED 2

31. How long ago did your household obtain the mosquito bed net?

MONTHS AGO___
MORE THAN 3 YEARS AGO 96

31A. How did you obtain the net?

BOUGHT IT AT COMMERCIAL PRICE 1
BOUGHT IT WITH VOUCHER OR OTHER SUBSIDY 2
RECEIVED IT FREE 3
OTHER (SPECIFY) ____ 6
DON'T KNOW 8

31B. When you got the mosquito bed net, was it treated with an insecticide?

YES, PRETREATED 1
NO, CAME WITH THE TREATMENT KIT AND I TREATED IT MYSELF 2 (SKIP TO 32A)
NO IT WAS NOT TREATED 3 (SKIP TO 32A)
OTHER (SPECIFY) ____ 6 (SKIP TO 32A)
DON'T KNOW 8 (SKIP TO 32A)

32. OBSERVE OR ASK THE BRAND OF MOSQUITO BED NET.

PERMANET 1
DAWA NET 2
OLYSET 3
LOCALLY MADE 4
OTHER 6
DON'T KNOW 8

32A. Since you got the mosquito bed net, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs?

YES 1
NO 2 (SKIP TO 32C)
DON'T KNOW 8

32B. How long ago was the net last soaked or dipped? IF LESS THAN 1 MONTH, RECORD '00'.

MONTHS AGO___
MORE THAN 3 YEARS AGO 96

32C. Did anyone sleep under this mosquito bed net last night?

YES 1
NO 2 (SKIP TO 32E)
DON'T KNOW (SKIP TO 32E)

32D. Who slept under this mosquito bed net last night? RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME ____
LINE NO____

32E. GO BACK TO 30 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 32F

32F In the past year, have you seen or heard messages about malaria:

On the television?
On the radio?
In a newspaper or magazine?
From a poster?
From leaflets or brochures?
From a health worker?

TELEVISION
YES 1
NO 2
RADIO
YES 1
NO 2
NEWSPAPER/MAGAZINE
YES 1
NO 2
POSTER
YES 1
NO 2
LEAFLETS/BROCHURES
YES 1
NO 2
HEALTH WORKER
YES 1
NO 2

32G. Have you seen or heard any messages telling you to give a child with fever chloroquine tablets for three days?

YES 1
NO 2
DON'T KNOW 8

32H. Have you ever listened to the radio program 'He Ha Ho?'

YES 1
NO 2
DON'T KNOW 8

33. Where do you usually wash your hands?

IN DWELLING/YARD/PLOT 1
SOMEWHERE ELSE 2 (GO TO 34A)
NOWHERE 3 (GO TO 34A)

34. ASK TO SEE THE PLACE AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT.

WATER/TAP
YES 1
NO 2
SOAP, ASH OR OTHER CLEANSING AGENT
YES 1
NO 2
BASIN
YES 1
NO 2

34A. Are you currently a member of a mutual health organization or health insurance scheme?

YES 1
NO 2 (GO TO 34E)
DON'T KNOW 8 (GO TO 34E)

34B. What type of scheme are you a member of?

PRIVATE HEALTH INSURANCE 1
MHO 2
GVT. HEALTH COVERAGE 3
OTHER (SPECIFY) ____ 6

34C. What benefits does your scheme cover?

CONSULTATION A
DRUGS B
LABORATORY COSTS C
X-RAY D
ADMISSION E
SURGERY F
SPECIALIST CARE G
EXTRA OR BETTER FEEDING IN HOSPITAL H
TRANSPORT I
ANTENATAL CARE J
NORMAL DELIVERY CARE K
COMPLICATED DELIVERY CARE L
FAMILY PLANNING M
OTHER (SPECIFY) ___ N

34D. Have you or any member of your family ever benefited from the scheme?

YES 1 (GO TO 35)
NO 2 (GO TO 35)
DON'T KNOW 8 (GO TO 35)

34E. Will you consider joining a scheme in the future?

YES 1
NO 2
DON'T KNOW 8

35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION).

0 PPM (NO IODINE) 1
7 PPM 2
15 PPM 3
ABOVE 30 PPM 4
NO SALT IN HH 5
SALT NOT TESTED (SPECIFY REASON) 6

HEIGHT, WEIGHT, HEMOGLOBIN MEASUREMENT, AND HIV TESTING

CHECK COLUMNS (2), (7), (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

WOMEN 15-49

36. LINE NO. FROM COL.(8)

_____

37. NAME FROM COL.(2)

_____

38. AGE FROM COL.(7)

YEARS __

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49

40. WEIGHT (KILOGRAMS)

_____.__

41. HEIGHT (CENTIMETRES)

_____.__

43. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

CHILDREN UNDER AGE 6

36 .LINE NO. FROM COL.(9)

_____


37. NAME FROM COL.(2)

_____

38. AGE FROM COL.(7)

YEARS __

39. What is (NAME)'s date of birth?

DAY __
MONTH__
YEAR____

WEIGHT AND HEIGHT OF CHILDREN BORN IN 1998 OR LATER

40. WEIGHT (KILOGRAMS)

____._

41. HEIGHT (CENTIMETRES)

____._

42. MEASURED LYING DOWN OR STANDING UP

LYING 1
STAND. 2

43. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

TICK HERE IF CONTINUATION SHEET USED

___

* FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM Q215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.

HEMOGLOBIN MEASUREMENT OF WOMEN 15-49

44. CHECK COLUMN (38):

AGE 15-17 1
AGE 18-49 2 (GO TO 46)

45. LINE NO. OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

__________

46. READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)

GRANTED 1 SIGN ______
REFUSED 2 (NEXT LINE)

47. HEMOGLOBIN LEVEL (G/DL)

____._

48. CURRENTLY PREGNANT

YES 1
NO/DK 2

49. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 1998 OR LATER

LINE NO. OF PARENT/ RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

____

READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)

GRANTED 1 SIGN_____
REFUSED 2 (NEXT LINE)

HEMOGLOBIN LEVEL (G/DL)

_____.___

* CONSENT STATEMENT

Hello, my name is (YOUR NAME) and I am from the Ghana Health Services and collaborating with the Ghana Statistical Service that is carrying out this health survey. As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all children born in 1998 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

May I now ask that you (and NAME OF CHILD[REN]) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

Note:
In countries where some enumeration areas are higher than 1,000 meters, altitude information should be collected for each enumeration area higher than 1,000 meters so that the anemia estimates can be adjusted appropriately.

50. CHECK 47 AND 48:
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT*

ONE OR MORE___ (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND CONTINUE WITH 51.**)
NONE___ (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND END HOUSEHOLD INTERVIEW.)

51. We detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)). This indicates that (you/NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem.

We would like to inform the doctor at __________ about (your condition/the condition of NAME OF CHILD(REN)). This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)) may be given to the doctor?

NAME OF PERSON WITH HEMOGLOBIN BELOW THE CUTOFF POINT

____________

NAME OF PARENT/RESPONSIBLE ADULT
(not necessary for women aged 18-49)
(indicate name of parent/responsible adult for women aged 15-17 and children)

________________

AGREES TO REFERRAL?

YES 1
NO 2

* The cutoff point is 9g/dl for pregnant women and 7g/dl for children and women who are not pregnant (or who don't know if they are pregnant.)

** If more than one woman or child is below the cutoff point, read the statement in Q.51 to each woman who is below the cutoff point and to each woman/parent/responsible adult of a child who is below the cutoff point.

HIV TESTING-WOMEN AND MEN

Total Number of Samples__

CHECK COLUMNS (8) AND (9A): WRITE LINE NUMBER, NAME, SEX, AND AGE OF WOMEN 15-49 AND MEN 15-59. THIS PAGE TO BE DESTROYED IN OFFICE BEFORE TEST RESULTS ARE ADDED TO DATA FILE.

52. LINE NO.FROM COL.(8) OR (9A)

______

53. NAME FROM COL.(2)

_____

54. SEX FROM COL.(4)

M 1
F 2

55. AGE FROM COL.(7)

YEARS___

56. CHECK AGE IN COL. (55):

15-17 1
18+ 2 (GO TO 59)

57. LINE NO. OF PARENT/RESPONSIBLE ADULT

____

58. READ THE CONSENT STATEMENT TO THE PARENT OR RESPONSIBLE ADULT
CIRCLE CODE (AND SIGN)

AGREES 1 SIGN____
REFUSES 2
NOT READ 3

59. READ THE CONSENT STATEMENT TO THE WOMAN OR MAN OR YOUTH
CIRCLE CODE (AND SIGN)

AGREES 1 SIGN _______
REFUSES 2
NOT READ 3

60. SAMPLE RESULT

1 SAMPLE TAKEN
2 REFUSED
3 NOT PRESENT
4 TECH. PROBLEM
6 OTHER (SPECIFY)

___ ___________

SAMPLE BAR CODE (61)

PASTE FIRST LABEL HERE. PASTE SECOND LABEL ON FILTER PAPER AND THIRD LABEL ON BLOOD SAMPLE TRANSMITTAL FORM.

CONSENT STATEMENT

Hello, my name is _______. I'm from the Ghana Health Services and collaborating with the Ghana Statistical Services. As part of this survey, we are studying HIV among women and men. As you know, HIV is the virus that causes AIDS. The government is trying to find out how common HIV is, so that they can develop programs to prevent HIV and care for those who have it.

We request that you participate in this test by giving a few drops of blood from a finger. For this test, I will use clean, sterile instruments that are completely safe. Blood will be tested later in the laboratory.

To ensure the confidentiality of this test result, no individual names will be attached to the blood sample; therefore, we will not be able to give you the result of your test and no one will be able to trace the test back to you. If you want to know whether you have HIV, I can tell you where you can go to get tested.

Do you have any questions?

I hope you will agree to participate in the HIV testing. But if you decide not to have the test done, it is your right and I will respect your decision. Will you accept to participate in the HIV test?

GO BACK TO COLUMN (59). CIRCLE THE APPROPRIATE CODE AND SIGN.

IF RESPONDENT IS AGE 15-17, ASK PARENT/GUARDIAN: Now, will you tell me if you accept for (NAME OF YOUTH) to participate in the HIV test?

GO TO COLUMN (58). CIRCLE THE APPROPRIATE CODE AND SIGN. IF PARENT AGREES, READ THE PRECEDING PARAGRAPHS TO YOUTH FOR HIS/HER CONSENT AND RECORD IN COL. (59).

NOTE FOR THE INTERVIEWER:

THE RESPONDENT HAS THE RIGHT TO REFUSE THE HIV TEST, AND THEREFORE SHOULD NOT BE FORCED.