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pdfUNITED 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/DCI 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:
1.3. 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/DCI.)
2.1. For each assay, check the appropriate box to indicate the Consortium/Task Force’s initial response in the following table and
follow the Order/DCI instructions to attach the data and/or required documentation
A. The Consortium/Task Force will generate new data.
B. The Consortium/Task Force is citing existing data and/or other scientifically relevant information.
C. The Consortium/Task Force 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/Task Force is citing and/or submitting other scientifically relevant information that it believes can be used to
satisfy all of the Order/DCI.
Required documentation is attached.
PART 3
Consortium/Task Force Participants:
3.1. Order/DCI #:
3.2. Company Names:
(Please list all participants, including Recipient information from the Order.)
3.3. Company Number(s):
3.4. Contact Name/Phone No.:
EDSPEDSPEDSPEDSPEDSPEDSPEDSP
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:
4.3. Date:
Signature:
Name and Title (Please Print or Type):
4.4. Phone Number:
Email address:
Submit Completed Form Using One of these Methods:
• Mail To: Document Processing Desk (PRD-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 (PRD-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
| File Type | application/pdf |
| File Title | Microsoft Word - EDSP-IRF-Consortium-2009-09-10.doc |
| Author | AHofmann |
| File Modified | 2009-09-10 |
| File Created | 2009-09-10 |