## 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 Ag ency, 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 O rder /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 i nitial r esponse in the following table and

follow the Order instructions to a ttach the data and /or required documentation

A

. The Consortium/Task Force w ill generate new data

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

. C. The Consortium/Task Force i s submitting existing data and/or other scientifically relevant information

. Assays: A B C R equired 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. T he Consortium/Task Force is citing and/or submitting other scientifically relevant information that it believe s 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 Name s: 3.3. Company Number(s): 3.4. Contact Name/Phone No.:

EDSP

EDSP

EDSP

EDSP

EDSP

EDSP

EDSP

-

 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:



### P ART 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 C DX.