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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 INDIVIDUAL ORDER RECIPIENTS
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
Recipient Information (From the Order/DCI – To be Completed by EPA):
1.1. Order/DCI Info:
A. Order/DCI #:
B. Date Issued:
1.2. Company Name:
C. Initial Response Due:
1.3. Address:
1.4. Contact Person:
1.5. Chemical Info:
PART 2
A. Chemical #:
B. Chemical Name:
C. Company #(s):
Recipient’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. I will generate new data or am citing/submitting existing data.
For each assay, check the appropriate box in the following table and follow Order instructions to attach required documentation.
A. I will generate new data.
B. I am citing existing data.
C. I am submitting existing data.
D. I am entering (or offering to enter) into an agreement to form a consortium to provide the data. Consortia must provide separate initial response
within 150 calendar days from issuance of the Order/DCI (see Initial Response Form for Consortium/Task Force at www.epa.gov/xxxxxxxxxxxx. )
Assays:
A
B
C
D
See attached documentation.
2.1.1. Amphibian Metamorphosis (Frog)
2.1.2. Androgen Receptor Binding (Rat Prostate)
2.1.3. Aromatase (Human Recombinant)
2.1.4. Estrogen Receptor Binding
2.1.5. Estrogen Receptor Transcriptional Activation (Human Cell Line (HeLa-9903))
2.1.6. Fish Short-term Reproduction
2.1.7. Hershberger (Rat)
2.1.8. Female Pubertal (Rat)
2.1.9. Male Pubertal (Rat)
2.1.10. Steroidogenesis (Human Cell Line – H295R)
2.1.11. Uterotrophic (Rat)
2.2. I am not subject to the Test Order/DCI.
See attached documentation.
These Response Options Apply Only to Registered Pesticides:
2.3. I intend to voluntarily cancel the pesticide registration(s).
See attached documentation.
2.4. I intend to reformulate the product(s) to exclude this chemical from the formulation.
See attached documentation.
2.5. I am claiming a Formulators’ Exemption.
See attached documentation.
These Response Options Apply Only to Chemicals that are Other Ingredients (aka inerts):
2.6. I have/am in the process of discontinuing the manufacture/import of this chemical.
See attached documentation.
2.7. I do not and will not sell my chemical for use as an inert ingredient to the pesticide market.
See attached documentation.
PART 3
3.1. 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.
3.2. Company’s Authorized Representative:
Signature:
3.3. Date:
3.4. 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 4
• 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
| File Type | application/pdf |
| File Title | Microsoft Word - EDSP-IRF-Individuals-2009-04-03.doc |
| Author | Ahofmann |
| File Modified | 2012-10-23 |
| File Created | 2009-04-08 |