## 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/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:

1.4. 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/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 atta ch the data and/or r equired documentation
A . The Consortium/Task Force will generate new data

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

. C. The Consortium/Task Force 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/Task Force is citing and/or submitting other sci entifically 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 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 addit ional 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 punis hable by fine or imprisonment or both under applicable law.

4.3. Date: 4.2. Consortium/Task Force’s Authorized Representative: Signature: Name and Title (Please Print or Type):
Email address: 4.4. Phone Number:



## PART 5 Submit Completed Form Using One of these Methods:
• Mail To: Document Processing Desk (PRD-EDSP), Office of Pesticide Programs (7504P), U. S. Environmental Protection Agency, 1200 Pennsylvania Ave. NW, Washington, D.C. 20460.
• Deliver To: Document Processing Desk (PRD-EDSP), Offi ce of Pesticide 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 throug h Friday, excluding legal holidays.

EPA Form No. 6300-05-C