### 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) Clear Form Data

OMB Control No.

2070

- TBD



### EDSP Tier 2 Testing, Initial Response Form for Individual Order Recipients

Paperwork Reduction Act Notice : The public reporting burden for this collection of information is estimated to average one hour per response.

Send comments regarding the burden estimate to: Director, Collection Strategies Division (2822T), U.S. Environmental Protecti on Agency,

Washington, DC 20460. Do not send the completed form to this address

– follow the submission instruc tions in the order/DCI and Part 4 below.



### Part 1 Recipient Information : (from the order/DCI and completed by the EPA)

A. Order/DCI #: B. Date Issued: C. Initial Response Due:

1.1. Order/DCI Info:

1.2. Company Name: 1.3. Address:

1.4. Contact Person:

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

1.5. Chemical Info:



### Part 2 Recipient’s Initial Response: (Please check the box next to your preferred response (2.1

– 2. 7 ). R efer 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 required test (  ) below , check the

appropriate box (A, B, or C) and follow the order/DCI instructions to attach the data and/or 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 Force to 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 EDSP Tier 2 Testing, Initial Response Form for Consorti a /Task Force s at http://www.epa.gov/endo/ .)

Required Test 

### A B C Documentation is

Attached 

###  OCSPP Guideline 890. 2100

, Japanese Quail Two

- Generation Toxicity 

###    

 OCSPP Guideline 890. 2200

, Medaka Extended One

- Generation Reproduction 

###    

 OCSPP Guideline 890. 2300 , Larval Amphibian Growth and Development 

###    

 OCSPP Guideline 870.3800, Reproduction and Fertility Effects * 

###    

* [OECD TG 416 (Two

- Generation Reproduction Toxicity Study) or

OECD TG 443 (Extended One

- Generation Reproductive Toxicity Study) are

acceptable alternatives to OCSPP Guideline 870.3800]



###  2.2 I am not subject to the order/DCI.



### These Response Options Apply Only to Registered Pesticides:



###  2.3 I intend to voluntarily cancel the pesticide registration (s)

. 

### 

 2.4 I intend to reformulate the product(s) to exclude this chemical from the formulation. 

### 

 2. 5 I am claim ing a formulator's exemption. 

### 

These Response Options Apply Only to Pesticide Inert Ingredients (aka, Inerts):



###  2. 6 I have / am in the process of discontinuing the manufacture/import of this chemical. 

### 

 2. 7 I do not and will not sell my chemical for use as an inert ingredient to the pesticide market. 

### 

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 3.3 Date

Signature:

Name & Title: 3.4 Telephone Number

Email Address:

Part 4 Detailed submission instruction s can be found on the EPA 's EDSP Internet homepage at http://www.epa.gov/endo

.

EPA Form No. 6300

- 07 (Draft, June 2015 )