EPA ICR No. 2488.01; Attachment D(4) 

EPA Form No. 6300-06-C 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, D.C. 20460

Endocrine Disruptor Screening Program (EDSP)

FFDCA §408(p) Order For SDWA 1457

OMB Control No. 

2070-tbd

INITIAL RESPONSE FORM for CONSORTIUM/ TASK FORCE

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 submission instructions in the Order 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: 1.3. Address: 

1.4. Contact Person:

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.) 

 2.1. For each assay, check the appropriate box to indicate the Consortium/Task Force’s initial response in the following table and 

follow the Order instructions to attach the data and/or required documentation

A. The Consortium/Task Force will generate new data. 

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

C. The Consortium/Task Force 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/Task Force 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/Task Force Participants: (Please list all participants, including Recipient 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 additional 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 punishable by fine or imprisonment or both under applicable law.

4.2. Consortium/Task Force’s Authorized Representative:

Signature:

Name and Title (Please Print or Type):

Email address:

4.3. Date:

4.4. Phone Number:

PART 5 

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/endo and follow 

the appropriate links to CDX.

SAMPLE