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 Agency, Washington, DC 

20460. Do not send the completed form to this address – follow the submission instructions 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: (Please refer to the Order 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 the Order instructions to attach the data and/or required documentation.

A. I will generate new data. 

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

C. I am entering (or offering to enter) into an agreement to form a Consortium/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 Order (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 

Order.  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)

SAMPLE