## UNITED STATES ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, D.C. 20460

Endocrine Disruptor Screening Program (EDSP) FFDCA §408(p) Order – SDWA §1457 Substance OMB Control No.
2070-0176



## INITIAL RESPONSE FORM for CONSORTIUM

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 and Part 5 below


## PART 1 Primary Contact Information (i.e., the Administrator of the Consortium):

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

1.2. Company/Consortium Name:

1.4. Contact Person: 1.3. Address:



## PART 2 Consortium’s Initial Response: (Please refer to the Order for more informat ion about response options, as well as detailed instructions on how to comply with the Order.)



###  2.1. For each assay, check the appropriate box to indicate the Cons ortium’s initial response in the following table and follow the Order
instructions to attach the dat a and/or required documentation
A . The Consortium will generate new data

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

. C. The Consortium is submitting existing data and/or other scientific ally 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 is citing and/or submi tting other scientifically relevant informati on that it believes can be used to satisfy all of the Order.  Required documentation is attached.



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

3.1. Order #: 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.

 See attached copy of the Consortium 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. Consortium’s Authorized Representative: Name and Title (Please Print or Type):
Email address: Signature: 4.4. Phone Number:



## PART 5 Submit Completed Form Using One of these Methods:
Mail To: Document Control Office (7407M), Office of Pollution Prevention and Toxics (OPPT), U.S. EPA, 1200 Pennsylvania Ave. NW, Washington, D.C. 20460-0001.
Deliver To: OPPT Document Control Office (DCO), EPA East Bldg., Rm. 6428, U.S. EPA, 1201 Constitution Ave. NW, Washington, D.C. 20004. [Deliveries are only accepted from 8:30 a.m. to 4 p.m., Monday through Friday, excluding legal holidays.]

EPA Form No. 6300-05-C-SDWA