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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 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/DCI and Part 4 below.
PART 1
Recipient Information (From the Order/DCI and 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/DCI.)
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 the Order/DCI instructions to attach the data and/or required documentation.
A. I will generate new data.
B. I am citing existing data and/or other scientifically relevant information.
C. I am submitting existing data and/or other scientifically relevant information.
D. I am entering (or offering to enter) into an agreement to form a Consortium/Task Force to respond to the Order/DCI. The Consortium/Task Force
must provide a 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
Required documentation is attached.
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 citing and/or submitting other scientifically relevant information that I believe can be used to satisfy all of the
Order/DCI.
Required documentation is attached.
2.3. I am not subject to the Order/DCI.
Required documentation is attached.
These Response Options Apply Only to Registered Pesticides:
2.4. I intend to voluntarily cancel the pesticide registration(s).
Required documentation is attached.
2.5. I intend to reformulate the product(s) to exclude this chemical from the formulation.
Required documentation is attached.
2.6. I am claiming a Formulators’ Exemption.
Required documentation is attached.
These Response Options Apply Only to Chemicals that are Other Ingredients (aka inerts):
2.7. I have/am in the process of discontinuing the manufacture/import of this chemical.
Required documentation is attached.
2.8. I do not and will not sell my chemical for use as an inert ingredient to the pesticide market.
Required documentation is attached.
3.1. Certification. I certify that the statements made on this form and all attachments are true, accurate and complete. I acknowledge that
PART 3
any knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law.
3.2. Company’s Authorized Representative:
3.3. Date:
Signature:
Name and Title (Please Print or Type):
3.4. 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 4
• 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
| File Type | application/pdf |
| File Title | Microsoft Word - EDSP-IRF-Individuals-2009-09-10.doc |
| Author | AHofmann |
| File Modified | 2009-09-10 |
| File Created | 2009-09-10 |