## 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 informat ion is estimated to average 1 hour per response. Send comments regarding the burden estimate to: Director, Collection St rategies Division (2822T), U.S. Environmental Protection Agen cy, 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 info rmation about response opti ons, 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 mu st 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/xxx xxxxxxxxx. ) 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 punis hable by fine or imprisonment or both under applicable law.

3.3. Date: 3.2. Company’s Authorized Representative: 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 Pestici de Programs (7504P), U.S. Environmental Protection Agency, 1200 Pennsylvania Ave. NW, Washington, D.C. 20460

• Deliver To: Document Processing Desk (SRRD-EDSP), Office of Pestici de 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 th rough Friday, excluding legal holidays.

EPA Form No. 6300-05