2249.02; Attachment M - [DRAFT] FFDCA §408(p) Order for SDWA Chemicals – Initial Response Form for Consortium” (EPA Form No. tba) (September 20, 2010). 

Draft 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, D.C. 20460 

Endocrine Disruptor Screening Program (EDSP) 

FFDCA §408(p) Order – SDWA §1457 Substance

OMB Control No. 

2070-0176

INITIAL RESPONSE FORM for CONSORTIUM

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 mailing instructions in the Order and Part 5 below 

PART 1 Primary Contact Information (i.e., the Administrator of the Consortium): 

1.1. Chemical Info: A. CAS #: B. Chemical Name: 

1.2. Company/Consortium Name: 1.3. Address: 

1.4. Contact Person: 

PART 2 Consortium’s Initial Response: (Please refer to the Order 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’s initial response in the following table and follow the Order 

instructions to attach the data and/or required documentation

A. The Consortium will generate new data. 

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

C. The Consortium 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 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 Participants: (Please list all participants, including Recipient information from the Order.)

3.1. Order #: 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.

 See attached copy of the Consortium 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’s Authorized Representative: 

Name and Title (Please Print or Type): 

Email address: 

Signature: 

4.3. Date: 

4.4. Phone Number: 

PART 5 

Submit Completed Form Using One of these Methods: 

Mail To: Document Control Office (7407M), Office of Pollution Prevention and Toxics (OPPT), U.S. EPA, 1200 Pennsylvania Ave. NW, 

Washington, D.C. 20460-0001. 

Deliver To: OPPT Document Control Office (DCO), EPA East Bldg., Rm. 6428, U.S. EPA, 1201 Constitution Ave. NW, Washington, D.C. 

20004. [Deliveries are only accepted from 8:30 a.m. to 4 p.m., Monday through Friday, excluding legal holidays.] 

EPA Form No. 6300-05-C-SDWA