## 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 INDIVIDUAL ORDER RECIPIENTS 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 4 below. 

## PART 1 Recipient Information (From the Order/DCI and Completed by EPA): 1.1. Order/DCI Info: A. Order/DCI #: B. Date Issued: C. Initial Response Due: 1.2. Company Name: 1.3. Address:

1.4. Contact Person:

1.5. Chemical Info: A. Chemical #: B. Chemical Name: C. Company #(s):



## PART 2 Recipient’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. I will generate new data or am citing/submitting existing data. For each assay, check the appropriate box in the following table and follow the Order/DCI instructions to attach the data and/o r required documentation. A. I will generate new data

. B. I am citing/submitting existing data and/or other scientifically relevant information

. C. I am entering (or offering to enter) into an agreement to form a Consortium/Task Forceto respond to the Order/DCI. The Consortium/Task Force must provide a separate initial response within 150 calendar days from issuance of the Order/DCI (see Initial Response Form forConsortium/Task Force at http://www.epa.gov/endo/ .) Assays: A B C Required documentation is attached. 2.1.1. Amphibian Metamorphosis (Frog)    2.1.2. Androgen Receptor Binding (Rat Prostate)    2.1.3. Aromatase (Human Recombinant)    2.1.4. Estrogen Receptor Binding    2.1.5. Estrogen Receptor Transcriptional Activation (Human Cell Line (HeLa-9903))    2.1.6. Fish Short-term Reproduction    2.1.7. Hershberger (Rat)    2.1.8. Female Pubertal (Rat)    2.1.9. Male Pubertal (Rat)    2.1.10. Steroidogenesis (Human Cell Line – H295R)    2.1.11. Uterotrophic (Rat)    

###  2.2. I am citing and/or submitting other scientifically relevant information that I believe can be used to satisfy all of the Order/DCI. Required documentation is attached. 

###  2.3. I am not subject to the Order/DCI. Required documentation is attached. 

### These Response Options Apply Onlyto Registered Pesticides:  2.4. I intend to voluntarily cancel the pesticide registration(s). Required documentation is attached. 

###  2.5. I intend to refo r mulate the product(s) to exclude this chemical from the formulation. Required documentation is attached. 

###  2.6. I am claiming a Formulators’ Exemption

. Required documentation is attached. 

### These Response Options Apply Onlyto Chemicals that are Other Ingredients (aka inerts):  2.7. I have/ am in the process of discontinuing the manufacture/import of this chemical. Required documentation is attached. 

###  2.8. I do not and will not sell my chemical for u se as an inert ingredient to the pesticide market. Required documentation is attached. 

## PART 3 3.1. 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. 3.2. Company’s Authorized Representative: Signature: Name and Title (Please Print or Type): Email address: 3.3. Date:
3.4. Phone Number:



## Part 4 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 

# SAMPLE EPA ICR No. 2488.01; Attachment D(1)

tbd

revised 3/2013