UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, D.C. 20460 

Endocrine Disruptor Screening Program (EDSP) 

FFDCA §408(p) Order/FIFRA §(3)(c)(2)(B) DATA CALL-IN (DCI)

OMB Control No. 

2070-[Insert]

INITIAL RESPONSE FORM for INDIVIDUAL ORDER RECIPIENTS 

Paperwork Reduction Act Notice: The public reporting burden for this collection of information is estimated to average 1 hour per response. Send 

comments regarding the burden estimate to: Director, Collection Strategies Division (2822T), U.S. Environmental Protection Agency, Washington, DC 

20460. Do not send the completed form to this address – follow the mailing instructions in the Order. 

PART 1 Recipient Information (From the Order/DCI – To be Completed by EPA): 

1.1. Order/DCI Info: A. Order/DCI #: B. Date Issued: C. Initial Response Due: 

1.2. Company Name: 

1.4. Contact Person: 

1.3. Address: 

1.5. Chemical Info: A. Chemical #: B. Chemical Name: C. Company #(s): 

PART 2 Recipient’s Initial Response: (Please refer to the Order/DCI for more information about response options, as well as detailed 

instructions on how to comply with the Order.) 

 2.1. I will generate new data or am citing/submitting existing data. 

For each assay, check the appropriate box in the following table and follow Order instructions to attach required documentation. 

A. I will generate new data. 

B. I am citing existing data. 

C. I am submitting existing data. 

D. I am entering (or offering to enter) into an agreement to form a consortium to provide the data. Consortia must provide separate initial response 

within 150 calendar days from issuance of the Order/DCI (see Initial Response Form for Consortium/Task Force at www.epa.gov/xxxxxxxxxxxx. ) 

Assays: A B C D See attached documentation. 

2.1.1. Amphibian Metamorphosis (Frog)     

2.1.2. Androgen Receptor Binding (Rat Prostate)     

2.1.3. Aromatase (Human Recombinant)     

2.1.4. Estrogen Receptor Binding     

2.1.5. Estrogen Receptor Transcriptional Activation (Human Cell Line (HeLa-9903))     

2.1.6. Fish Short-term Reproduction     

2.1.7. Hershberger (Rat)     

2.1.8. Female Pubertal (Rat)     

2.1.9. Male Pubertal (Rat)     

2.1.10. Steroidogenesis (Human Cell Line – H295R)     

2.1.11. Uterotrophic (Rat)     

 2.2. I am not subject to the Test Order/DCI.  See attached documentation. 

These Response Options Apply Only to Registered Pesticides:

 2.3. I intend to voluntarily cancel the pesticide registration(s).  See attached documentation.

 2.4. I intend to reformulate the product(s) to exclude this chemical from the formulation.  See attached documentation.

 2.5. I am claiming a Formulators’ Exemption.  See attached documentation.

These Response Options Apply Only to Chemicals that are Other Ingredients (aka inerts):

 2.6. I have/am in the process of discontinuing the manufacture/import of this chemical.  See attached documentation.

 2.7. I do not and will not sell my chemical for use as an inert ingredient to the pesticide market.  See attached documentation.

PART 3 3.1. Certification. I certify that the statements made on this form and all attachments are true, accurate and complete. I acknowledge that 

any knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law. 

3.2. Company’s Authorized Representative: 3.3. Date: 

Signature: 

Name and Title (Please Print or Type): 

Email address:

3.4. Phone Number: 

Part 4 

Submit Completed Form By: 

• Mail To: Document Processing Desk (SRRD-EDSP), Office of Pesticide Programs (7504P), U.S. Environmental Protection Agency, 1200 

Pennsylvania Ave. NW, Washington, D.C. 20460 

• Deliver To: Document Processing Desk (SRRD-EDSP), Office of Pesticide Programs (7504P), U.S. Environmental Protection Agency, 

One Potomac Yard (South Bldg.), 2777 S. Crystal Dr., Arlington, VA. Deliveries are only accepted 8:30 a.m. to 4 p.m., Monday through 

Friday, excluding legal holidays. 

EPA Form No. 6300-05