## 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 CONSORTIUM/ TASK FORCE

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 Primary Contact Information (i.e., the Administrator of the Consortium/Task Force):

1.1. Chemical Info: A. Chemical #: B. Chemical Name:

1.2. Company/Consortium/Task Force Name:

1.4. Contact Person: 1.3. Address:



## PART 2 Consortium/Task Force’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.)



### For each assay, check the appropriate box to in dicate your response in the following table.
A . The Consortium/Task Force will generate new data

. B. The Consortium/Task Force is citing existing data . (Follow Order instructions to attach the full citation to publicly available data.)
C. The Consortium/Task Force is submitting existing data . (Follow Order instructi ons to attach the data.) Assays: A B C See attached documentation.
1. Amphibian Metamorphosis (Frog)    2. Androgen Receptor Binding (Rat Prostate)   
3. Aromatase (Human Recombinant)   
4. Estrogen Receptor Binding   
5. Estrogen Receptor Transcriptional Activation (Human Cell Line (HeLa-9903))    6. Fish Short-term Reproduction    7. Hershberger (Rat)   
8. Female Pubertal (Rat)   
9. Male Pubertal (Rat)    10. Steroidogenesis (Human Cell Line – H295R)   
11. Uterotrophic (Rat)   



## PART 3 Consortium/Task Force Participants: (Please list all participants, including Re cipient information from the Order.)

3.1. Order/DCI #: 3.2. Company Names: 3.3. Company Number(s): 3.4. Contact Name/Phone No.:

EDSPEDSPEDSPEDSPEDSPEDSPEDSP-

See attached continuation sheet identifying additional participants.

See attached copy of the Consortium/Task Force agreement.



## PART 4 4.1. 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.

4.3. Date: 4.2. Company’s Authorized Representative: Signature:

Name and Title (Please Print or Type):
Email address: 4.4. Phone Number:



## Part 5 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-C