EPA Form No. 6300

- 06 

### UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, D.C. 20460

Endocrine Disruptor Screening Program (EDSP)

FFDCA §408(p) Order For SDWA 1457 OMB Control No.

2070

- tbd



### 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 Ag ency, Washington, DC

20460. Do not send the completed form to this address

– follow the submission inst ructions in the Order and Part 4 below

.



### PART 1 Recipient Information (From the Order and Completed by EPA):

1. 1. Order Info: A. Order #: B. Date Issued: C. Initial Response Due:

1

. 2. Company Name: 1

. 3. Address:

1

. 4. Contact Person:

1.5

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



### PART 2 Recipient’s Initial Response: ( Plea se refer to the O rder 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 f ollow the Order instructions to attach the data and/or required documentation.

A. I will generate new data

. B. I am cit ing/submitting existing data and/ or other scientifically relevant information

. C. I am entering (or offer ing to enter) into an agreement to form a C onsortium /Task Force to respond to the Order

. The Consortium/Task Force must

provide a separate initial response within 150 calendar days from issuance of the O rder (see Initial Response Form for Consortium/Task Force at

http://www.epa.gov/endo/

. )

Assays: A B C Required documentation is attached.

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 citing and/or submitting other scientifically relevant information that I believe can be used to satisfy all of the

O rder.  Required documentation is attached

.



###  2. 3

. I am not subject to the Order

.  Required documentation is attached.



###  2. 4

. I do not, or will not continue to manufacture or import this chemical.  Required documentation is attached.



### 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:

Signature:

Name and Title (Please Print or Type):

Email address: 3.3. Date:

3.4. Phone Number:



### Part 4 Your response to this Order and all related correspondence must be submitted electronically to the EPA using the following

methods:

• Submissions must be sent electronically to EPA via CDX.

• Access the EDSP electronic reporting tool and instruction on the EPA EDSP Internet homepage at http://www.epa.gov/endo and follow

the appropriate links to CDX. 

## EPA ICR No. 2488.01; Attachment D (3)