Attachment D(2) - Response Form for Consortia

Attachment D - (2)

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460

OMB Control No.
2070-[Insert]

Endocrine Disruptor Screening Program (EDSP)
FFDCA §408(p) Order/FIFRA §(3)(c)(2)(B) DATA CALL-IN (DCI)
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 mailing instructions in the Order

PART 1

Primary Contact Information (i.e., the Administrator of the Consortium/Task Force):

1.1. Chemical Info:

A. Chemical #:

B. Chemical Name:
1.3. Address:

1.2. Company/Consortium/Task Force Name:
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.)

For each assay, check the appropriate box to indicate your response in the following table.
A. The Consortium/Task Force will generate new data.
B. The Consortium/Task Force is citing existing data. (Follow Order instructions to attach the full citation to publicly available data.)
C. The Consortium/Task Force is submitting existing data. (Follow Order instructions to attach the data.)
Assays:
A B C See attached documentation.
€ € € …
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)

PART 3

Consortium/Task Force Participants:

3.1. Order/DCI #:

(Please list all participants, including Recipient information from the Order.)

3.2. Company Names:

3.3. Company Number(s):

3.4. Contact Name/Phone No.:

EDSPEDSPEDSPEDSPEDSPEDSPEDSP… See attached continuation sheet identifying additional participants.
… 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. Company’s Authorized Representative:
Signature:

4.3. Date:

4.4. Phone Number:
Name and Title (Please Print or Type):
Email address:
Submit Completed Form By:
• Mail To: Document Processing Desk (SRRD-EDSP), Office of Pesticide Programs (7504P), U.S. Environmental Protection Agency, 1200
Pennsylvania Ave. NW, Washington, D.C. 20460
Part 5
• Deliver To: Document Processing Desk (SRRD-EDSP), Office of Pesticide Programs (7504P), U.S. Environmental Protection Agency,
One Potomac Yard (South Bldg.), 2777 S. Crystal Dr., Arlington, VA. Deliveries are only accepted 8:30 a.m. to 4 p.m., Monday through
Friday, excluding legal holidays.
EPA Form No. 6300-05-C