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 informat ion is estimated to average 1 hour per response. Send comments regarding the burden estimate to: Director, Collection St rategies Division (2822T), U.S. Environmental Protection Agen cy, 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 informat ion 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 Cons ortium’s initial response in the following table and follow the Order instructions to attach the dat a 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 submi tting other scientifically relevant informati on 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 Re cipient 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 punis hable 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 Prev ention 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