## 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- 0176



## INITIAL RESPONSE FORM for CONSORTIUM/ TASK FORCE 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 Agen cy, Washington, DC 20460. Do not send the completed form to this address – follow the submission instructions in the Order/DCI and Part 5 below 

## 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: 1.3. Address:
1.4. Contact Person:


## 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/DCI.) 

###  2.1.For each assay, check the appropriate box to indicate the C onsortium/Task Force’s initial response in the following table an d follow the Order/DCI instructions to attachthe data and/or required documentation A . The Consortium/Task Force will generate new data

. B.The Consortium/Task Force is citing existing data and/or other scientifically relevant information

. C.The Consortium/Task Force is submitting existing data and/or other scientifically relevant information

. Assays: A B C Required documentation is attached. 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)    

###  2.2.The Consortium/Task Force is citing and/or submitting other scientifically relevant information that it believes can be used to satisfy all of the Order/DCI. Required documentation is attached. 

## PART 3 Consortium/Task Force Participants: (Please list all participants, including Recipient 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 in the Consortium/Task Force. 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 punishable by fine or imprisonment or both under applicable law. 4.2. Consortium/Task Force’s Authorized Representative: Signature: Name and Title (Please Print or Type): Email address: 4.3. Date:
4.4. Phone Number:



## PART 5 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/endoand follow the appropriate links to CDX. EPA Form No. 6300-05-C 

# SAMPLE EPA ICR No. 2488.01; Attachment D(2)

tbd

revised 3/2013