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 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 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 information 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 Consortium’s initial response in the following table and follow the Order 

instructions to attach the data 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 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 is citing and/or submitting other scientifically relevant information 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 Recipient 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 punishable by fine or imprisonment or both under applicable law. 

4.2. Consortium’s Authorized Representative: 4.3. Date: 

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