1
Please contact with any
questions and return
original form to:
Biological Safety Officer
Office of Environmental Health & Safety
Box 1914
401-863-3087
IBC # __________ Date ____________
Action __________________________
▲For EH&S Use Only ▲
Please refer to the IBC Policy at http://www.brown.edu/biosafety
Principal Investigator (Last Name, First Name)
Biological Research Authorization Title:
Academic Title:
Email address:
Department/Campus Box:
Division:
Laboratory Location(s) if unchanged:
Current IBC #
Amendment # and Approval Date of Original Application (e.g.
amendment #3, original application approval date 2/29/10):
Office Phone #:
Lab Phone #:
Laboratory Supervisor (if not PI) Printed Name and Approval Signature:
Include A copy of the original Biological Research Authorization project overview (question 12 a-c) and a summary statement
explaining the reason for the amendment with this amendment.
Select Type(s) of Change:
A.
Change of Location (laboratory, animal housing, equipment room etc.):
(List all rooms in which this research will impact the space or equipment including the change of location. Include rooms that are not
changing and indicate “no change.” If the new location of the research is a shared space, the responsible PI for the shared space
must complete the form on page 2):
Add
B.
Remove
No
Change
Building
Room & Responsible
Person
Purpose
Equipment (e.g., BSC,
Incubator, etc.)
Change of Biological Agent: If the scope of your work will include several different agents please list them in a single
amendment. If the agents added in this amendment are genetically modified or if the object of your research includes modification, complete
part D. If there is an available therapeutic treatment or Post Exposure Prophylaxis for the agent(s) please include an attachment . *
(Indicate which agents are still in use on the related protocol and indicate “no change” and which are added or discontinued):
Add
C.
Remove
No
Change
Agent
Strain
BSL
Genetically
Modified?
Comments
Significant Change of Procedure or Agent: Complete the relevant parts of the Biological Research Authorization BS0-1* form including a
brief overview of the new scope of research containing sufficient information to ensure adequate review of the protocol to determine compliance
with the Brown University Biosafety Program, local, state, and federal regulations.
*If the change in the procedure or agent will require a change to your Exposure Control Plan (i.e., changes in disinfection procedures, lab
practices or engineering controls) please include an updated Exposure Control Plan. The template can be found at the
following URL:
http://www.brown.edu/Administration/EHS/biological/ )
As Principal Investigator, I accept responsibility for the safe conduct of work with this material. I will ensure that all personnel receive
training in regard to proper safety practices and protective equipment needed for this work.
Signature (Principal Investigator) __________________________________________________
(Signature may be an inserted electronic image of your actual signature)
Brown University Environmental Health and Safety
Created: November 2011
Reviewed: March 2013
BSO-3
Date: ___________
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This form letter must be electronically signed by the PI listed on page 2 with whom you share lab/storage space,
housing (when applicable) or equipment. Please send to all applicable PI’s. Once signed, this form must be
emailed to you (the Biological Research Authorization applicant) and forwarded to the Biological Safety Officer or
emailed directly to the Biological Safety Officer.
Dear Members of the Brown Institutional Biosafety Committee (IBC),
I have reviewed, evaluated and understand the project entitled: ___________________________________________
submitted to the IBC by: ______________________________________. I believe the information contained in this
application is accurate and complete. I agree to abide by the provisions of the application, the Exposure Control Plan
(where applicable to my space, equipment or personnel), current NIH Guidelines, the NIH Guide for Grants and Contracts,
Brown University policies and procedures, and local, state, and federal regulations.
If I feel that the procedures listed in the application or ECP are not being followed, I will address this issue with the
applicant PI and if necessary, the Biological Safety Officer.
I accept responsibility for the safe conduct of this work ONLY as it applies to my space, equipment or personnel. I will ensure that all
applicable personnel receive training in regard to proper safety practices and protective equipment needed for this work.
Electronic Signature (Principal Investigator) __________________________________________________
Brown University Environmental Health and Safety
Created: November 2011
Reviewed: March 2013
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Date: ____________________
3
I. SYNTHETIC/RECOMBINANT DNA EXPERIMENTS: I. SYNTHETIC/RECOMBINANT DNA EXPERIMENTS: (Indicate “yes or no” for each
question per relevant part [I. and A-D] to determine the section of the NIH Guidelines under which your research falls. Please note: inclusion in one
section may exclude your work from another e.g., if your work can best be categorized as fitting under section III-D-4-a of the Guidelines, it won’t likely
also fall under sections in III-F). All researchers using synthetic/recombinant nucleic acids must make this determination. )
http://oba.od.nih.gov/rdna/nih_guidelines_new.htm
YES NO

 The recombinant or synthetic nucleic acid molecules in your experiment can neither replicate nor generate nucleic acids that can
replicate in any living cell (e.g., oligonucleotides or other synthetic nucleic acids that do not contain an origin of replication or
contain elements known to interact with either DNA or RNA polymerase), and (2) are not designed to integrate into DNA, and (3)
do not produce a toxin that is lethal for vertebrates at an LD50 of less than 100 nanograms per kilogram body weight. If yes, the molecules
meet all 3 of the above criteria e.g., “they can neither replicate…” or “are not designed to integrate…” or “do not produce a
toxin…” , your research is categorized under section III-F-1 of the NIH Guidelines.


Are the recombinant or synthetic nucleic acid molecules in your experiment in organisms, cells , or viruses or have they been
modified or manipulated (e.g., encapsulated into synthetic or natural vehicles) to render them capable of penetrating cellular
membranes.? If no, your research is categorized under III-F-2 of the NIH Guidelines.


Do the recombinant or synthetic nucleic acid molecules in your experiment consist solely of the exact recombinant or synthetic
nucleic acid sequence from a single source that exists contemporaneously in nature? If yes, your research is categorized under
section III-F-3 of the NIH Guidelines.


Do the recombinant or synthetic nucleic acid molecules in your experiment consist entirely of nucleic acids from a prokaryotic host,
including its indigenous plasmids or viruses when propagated only in that host (or a closely related strain of the same species), or
when transferred to another host by well established physiological means? If yes, your research is categorized under III-F-4 of the NIH
Guidelines.


Do the recombinant or synthetic nucleic acid molecules in your experiment consist entirely of nucleic acids from a eukaryotic host
including its chloroplasts, mitochondria, or plasmids (but excluding viruses) when propagated only in that host (or a closely related
strain of the same species)? If yes, your research is categorized under III-F-5 of the NIH Guidelines.


Do the recombinant or synthetic nucleic acid molecules in your experiment consist entirely of DNA segments from different species
that exchange DNA by known physiological processes, though one or more of the segments may be a synthetic equivalent? See
Appendices A-I through A-VI, Exemptions Under Section III-F-6— Sublists of Natural Exchangers, for a list of natural exchangers
that are exempt from the NIH Guidelines. If yes, your research is categorized under III-F-6 of the NIH Guidelines.


Does your experiment involve the use of genomic DNA molecules that have acquired a transposable element, provided the
transposable element does not contain any recombinant and/or synthetic DNA? If yes, your research is categorized under III-F-7 of
the NIH Guidelines.


Do the recombinant or synthetic nucleic acid molecules in your experiment present a significant risk to health or the environment
(see Section IV-C-1-b- (1)-(c) as determined by the NIH Director, with the advice of the RAC, and following appropriate notice and
opportunity for public comment) NOR fall under any other sections of the NIH Guidelines? See Appendix C, Exemptions under Section III-F-8
for other classes of experiments which are exempt from the NIH Guidelines. If your experiment does not pose a significant risk to health
or the environment AS DETERMINED BY THE NIH DIRECTOR ETC., your research is categorized under III-F-8 of the NIH Guidelines
after approval from NIH/RAC. If your research does not pose a significant risk to health or the environment AND has NOT been
reviewed by the NIH Director, leave this question blank.


Does your research involve breeding two different transgenic rodents or a transgenic rodent and a non-transgenic rodent with the intent of
creating a new strain of transgenic rodent that can be housed at BL1 containment AND
(1) Both parental rodents can be housed under BL1 containment; and
(2) neither parental transgenic rodent contains the following genetic modifications: (i) incorporation of more than one-half of the genome of an
exogenous eukaryotic virus from a single family of viruses; or (ii) incorporation of a transgene that is under the control of a gammaretroviral
long terminal repeat (LTR); and
(3) the transgenic rodent that results from this breeding is not expected to contain more than one-half of an exogenous viral genome from a
single family of viruses?
If yes, this procedure is categorized under Appendix C-VIII of the NIH Guidelines.
A.
TISSUE CULTURE EXPERIMENTS INVOLVING SYNTHETIC/RECOMBINANT DNA
YES NO

 Do the recombinant or synthetic nucleic acid molecules in your experiment that are propagated and maintained in cells in
tissue culture contain less than one-half of any eukaryotic viral genome (all viruses from a single family being considered
identical – see Appendix C-IX-E, Footnotes and References of Appendix C)? If yes, your research is categorized under
Appendix C-1 of the NIH Guidelines.


Do any recombinant or synthetic nucleic acid experiments involve Risk Groups 3, 4 or restricted organisms or nucleic acids
from Risk Groups 3, 4 or restricted organisms? If no, your research is categorized under Appendix C-1 of the NIH Guidelines.


Do any recombinant or synthetic nucleic acid experiments involve introduction of genes coding for molecules toxic for
Brown University Environmental Health and Safety
Created: November 2011
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vertebrates? If no, your research is categorized under Appendix C-1 of the NIH Guidelines.


Do any recombinant or synthetic nucleic acid experiments involve infectious viruses? If no, research is categorized under Appendix
C-1 of the NIH Guidelines


Do any recombinant or synthetic nucleic acid experiments involve defective viruses in the presence of helper viruses? If no,
your research is categorized under Appendix C-1 of the NIH Guidelines.


Do any recombinant or synthetic nucleic acid experiments involve whole plants regenerated from plant cells and tissue
cultures? If yes AND they remain axenic cultures even though they differentiate into embryonic tissue and regenerate
into plantlets, your research is categorized under Appendix C-1 of the NIH Guidelines.
B. EXPERIMENTS INVOLVING E.COLI K-12, YEAST, KLUYVEROMYCES LACTIS BACILLUS SUBTILIS/LICHENIFORMIS HOSTVECTOR SYSTEMS
YES NO

 Do any experiments involve Risk Groups 3, 4 or restricted organisms or nucleic acids from Risk Groups 3, 4 or restricted
organisms? If no, your research is categorized under Appendix C-II (for E. coli K-12) or Appendix C-III (for Saccharomyces
cerevisiae and Saccharomyces uvarum), Appendix C-IV (for Kluyveromyces lactis) or Appendix C-V (for Bacillus
subtilis/licheniformis).
.


Do any experiments involve introduction of genes coding for molecules toxic for vertebrates? If no, your research is categorized
under Appendix C- II (for E. coli K-12) or Appendix C-III (for Saccharomyces cerevisiae and Saccharomyces uvarum), Appendix
C-IV (for Kluyveromyces lactis or Appendix C-V (for Bacillus subtilis/licheniformis).


Will there be any large-scale experiments (more than 10 L of culture)? If no, your research is categorized under Appendix CII (for E. coli K-12) or Appendix C-III (for Saccharomyces cerevisiae and Saccharomyces uvarum), Appendix C-IV (for
Kluyveromyces lactis) or Appendix C-V (for Bacillus subtilis/licheniformis).


If using asporogenic Bacillus subtilis or asporogenic Bacillus licheniformis, are you using a strain which does not revert to a
spore-former with a frequency greater than 10-7? If yes, your research is categorized under Appendix C-V (for Bacillus
subtilis/licheniformis).
C. SYNTHETIC/RECOMBINANT DNA EXPERIMENTS THAT REQUIRE IBC APPROVAL AND DO NOT FALL INTO THE ABOVE SECTIONS
YES NO

 Is any human or animal pathogen (defined as a Risk Group 2, Risk Group 3, Risk Group 4, or Restricted Agents) used as
either the host organism or as a vector? If yes, your research is categorized under III-D-1 of the NIH Guidelines.


Is any recombinant or synthetic nucleic acid molecules from Risk Group 2, Risk Group 3, Risk Group 4 or restricted agents
cloned into nonpathogenic prokaryotic or lower eukaryotic host-vector systems? If yes, your research is categorized under
III-D-2 of the NIH Guideilnes.


Do recombinant or synthetic nucleic acid or RNA experiments involve the use of infectious DNA or RNA Viruses or Defective
DNA or RNA Viruses in the Presence of Helper Virus in Tissue Culture Systems? If yes, your research is categorized under
III-D-3 of the NIH Guidelines.


Do recombinant or synthetic nucleic acid or RNA experiments involve the use of defective animal or plant viruses in the
presence of helper virus in tissue culture systems? If yes, your research is categorized under III-D-3 of the NIH Guidelines.


Do recombinant or synthetic nucleic acid or RNA experiments involve whole animals (Section III-D-4) or plants (Section III-D5)? Indicate which________________ .


Do experiments involve more than 10 liters of culture? If yes, your research is categorized under III-D-6 of the NIH Guidelines.


Do experiments involve influenza viruses generated by recombinant or synthetic methods (e.g., generation by reverse
genetics of chimeric viruses with reassorted segments, introduction of specific mutations)? If yes, your research is categorized
under III-D-7of the NIH Guidelines.


Do experiments NOT fall under sections III-A, III-B, III-C, III-D, III-F of the NIH Guidelines AND involve the formation of recombinant or
synthetic nucleic acid molecules containing no more than two-thirds of the genome of any eukaryotic virus? If yes, your research is
categorized under III-E-1 of the NIH Guidelines.


Do experiments NOT fall under sections III-A, III-B, III-C, III-D, III-F of the NIH Guidelines AND involve nucleic acid molecule-modified
whole plants, and/or experiments involving recombinant or synthetic nucleic acid molecule-modified organisms associated with whole
plants? If yes, your research is categorized under III-E-2 of the NIH Guidelines.


Do experiments NOT fall under section III-D-4 and involve the generation of rodents in which the animal's genome has been altered by
stable introduction of recombinant or synthetic nucleic acid molecules, or nucleic acids derived therefrom, into the germ-line (transgenic
rodents)but can be conducted at BSL-1? If yes, your research is categorized under III-E-3-a of the NIH Guidelines.
.
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D. EXPERIMENTS THAT REQUIRE IBC, RAC REVIEW AND NIH DIRECTOR APPROVAL BEFORE INITIATION (III-A), EXPERIMENTS
THAT REQUIRE NIH/OBA AND IBC APPROVAL BEFORE INITIATION (III-B), AND EXPERIMENTS THAT REQUIRE IRB AND IBC
APPROVAL AND NIH/OBA REGISTRATION BEFORE INITIATION APPROVAL BEFORE INITIATION (III-C)
YES NO

 Does the research involve the transfer of drug resistance trait to an organism that does not acquire it normally (if it could
compromise the use of the drug to control disease agents in humans, animal or agriculture) ? If yes, your research is categorized
under III-A-1 of the NIH Guidelines.
.


Does the experiment involve the formation of recombinant or synthetic nucleic acid containing genes coding for the synthesis
of molecules toxic for vertebrates? If yes, your research is categorized under III-B-1 of the NIH Guidelines.


Does the experiment involve human gene transfer experiments? If yes, your research is categorized under III-C-1 of the
NIH Guidelines.
E. Describe below, specific host(s), vector(s), DNA(s) and what proteins will be produced? (NOTE: Recombinant/synthetic nucleic acid
molecules work that falls under any of the III-F sections or Appendices CI-CVIII excluding excepted paragraphs A, need not be described here and
you may skip directly to part F of this section. Otherwise, please complete.)
Host Cells:_________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Vector(s): _________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Inserted DNA/Synthetic Nucleic Acid Molecule:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Protein produced (if applicable):________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

THE EXPERIMENTS IN THIS AUTHORIZATION CAN BE CATEGORIZED UNDER NIH GUIDELINES SECTION(S)(list all that
apply):_____________________________________________________________________________________
F. Can your experiment or part of your experiment be listed under sections III-A, III-B, III-C, III-D, III-E-1 or III-E-2 of the NIH Guidelines?
 Yes If yes, complete parts G and H of this application. If your project includes experiments that fall under sections
III-A, III-B, III-C, III-D, III-E-1, III-E-2
III-F, III-E-3a or Appendices CI-CVIII OF NIH Guidelines, complete parts G
and H of this application.
No If no, a.) Describe why your research (or part of your research) fits into section III-F, III-E-3a or Appendices CI-CVIII of the NIH
Guidelines and provide a brief summary of your research.
b.) Describe key features of any key features cell line, virus or bacteria used in this project and if the experiments will
result in acquisition of new characteristics e.g., enhanced virulence, infectivity, drug resistance, or change in host
range. Give references if appropriate.
c.) Describe the source of the DNA/synthetic nucleic acid molecules, the nature of the inserted DNA/synthetic nucleic acid
molecules sequences, the host(s) and vector(s) to be used, if an attempt will be made to obtain expression of a foreign
gene and what protein will be produced. Be sure to account for whether or not the genes involved or expressed have
potential: toxicity, allergenicity or other risk to research personnel
d.) Percent of the pathogen genome present in the vector (kilobases of the parent pathogen in the vector and packaging
cell combined).
e.) Outline the general procedures and techniques that will be employed e.g., cell culture, bacterial culture, DNA isolation.
f.) Complete a copy of the Exposure Control Plan (page 13).
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________________________________________ INCLUDE AS ATTACHMENT IF NECESSARY
G. If your experiment or part of your experiment can be listed under sections III-A, III-B, III-C, III-D, III-E-1 or III-E-2 of the NIH Guidelines,
please complete the following fields. In submitting this application, you agree to understand and comply with the Principal Investigator
responsibilities outlined in section IV-B-7 of the NIH Guidelines found here:
http://oba.od.nih.gov/oba/rac/Guidelines/NIH_Guidelines.htm#_Toc7261589
Brown University Environmental Health and Safety
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i.
Provide a brief summary of your research involving recombinant or synthetic nucleic acid molecules in non-technical language
INCLUDE AS ATTACHMENT IF NECESSARY:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________.
ii.
Will the experiment be carried out in E. coli or other prokaryotic host?
 Yes
 No
If yes, specify: _________________________________________________________________________________________
Host strains: ___________________________________________________________________________________________
Vectors: _______________________________________________________________________________________________
Inserted DNA/synthetic nucleic acid molecules (include names of genes and organisms from which they were cloned):
_______________________________________________________________________________________________________
Will whole virus or provirus be cloned?
 Yes
 No
NIH Guideline Section: _________________________ Recommended Biosafety Level: __________________________
iii. Will the experiment be carried out in eukaryotic cells?
 Yes
 No
If yes, specify: _________________________________________________________________________________________
Host strains: ___________________________________________________________________________________________
Vectors: _______________________________________________________________________________________________
Inserted DNA/synthetic nucleic acid molecules:
_______________________________________________________________________________________________________
Helper virus or packaging cells if used: ____________________________________________________________________
What fraction of a eukaryotic viral genome is contained in the recombinant DNA molecules (including vector and insert)?
 <1/2
 >1/2 but <2/3
 >2/3
NIH Guidelines Section: _________________________ Recommended Biosafety Level: __________________________
iv. Will the experiment be carried out using whole plants or animals as hosts?  Yes
 No
If yes, specify: _________________________________________________________________________________________
Host strains: ___________________________________________________________________________________________
Vectors: _______________________________________________________________________________________________
Inserted DNA/synthetic nucleic acid molecules: ______________________________________________________________
________________________________________________________________________________________________________
Helper virus or packaging cells if used: ____________________________________________________________________
What fraction of a eukaryotic viral genome is contained in the recombinant DNA/synthetic nucleic acid molecule?
 <2/3
 >2/3
NIH Guidelines Section: _________________________ Recommended Biosafety Level: __________________________
v. Will any of the sequences code for toxins?
 Yes (LD50)__________  No
vi. Will VSV-G be used for pseudotyping and are you aware that this can increase the risk of exposure through absorption and
inhalation along with injection and ingestion?
 Yes

 No
vii. If using adeno or lentivirus, will you be using third or fourth generation systems for safety? 
 Yes
 No
viii. If using oncogene inserts, a DNA sequencing library shall be kept. Indicate the location of these
records____________________________
H. SPECIFIC NUCLEIC ACID INFORMATION
a.) Describe the source of the DNA/synthetic nucleic acid molecules, the nature of the inserted DNA/synthetic nucleic acid
molecules sequences, the host(s) and vector(s) to be used, if an attempt will be made to obtain expression of a foreign
gene and what protein will be produced. Be sure to account for whether or not the genes involved or expressed have potential:
toxicity, allergenicity or other risk to research personnel
b.) Attach vector maps
c.)Describe key features of the agent, virus or bacteria used in this project and if the experiments will result in acquisition
of new characteristics e.g., enhanced virulence, infectivity, drug resistance, or change in host range. Give references if
appropriate.
d.) Percent of the pathogen genome present in the vector (kilobases of the parent pathogen in thevector and packaging cell
combined).
e.) Will the research involve the use of antibiotic selection markers?  Yes  No If yes, list the markers and microbial agents used
(e.g. neomycin resistance marker in E. coli)
f.) Complete a copy of the Exposure Control Plan (page 13). INCLUDE AS ATTACHMENT IF NECESSARY
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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Brown University Environmental Health and Safety
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The application form (summary and any attachments) must provide sufficient detail for the Biological Safety Committee to
understand and evaluate recombinant or synthetic nucleic acid molecules of the project in order to review the application.
For attached published references, please highlight pertinent paragraphs or sentences. Submissions that lack detail or
are illegible will be deferred from action and returned for revision and resubmission. Incomplete applications will be
returned.
Certification and Signature
The information contained in this application is accurate and complete. I am familiar with and agree to abide by the
provisions of the current NIH Guidelines, the NIH Guide for Grants and Contracts, Brown University policies and
procedures, and local, state, and federal regulations.
In addition, I agree to abide by the following requirements:
a. I will initiate no recombinant or synthetic nucleic acid molecule research subject to the NIH Guidelines until
that research has been reviewed by the Biological Safety Committee.
b. I will follow appropriate biosafety level laboratory techniques in the research.
c. I will comply with all shipping requirements for recombinant or synthetic nucleic acid materials.
d. I will make available to the laboratory staff copies of the approved protocols that describe the potential
biohazards and the precautions to be taken.
e. I will have a specific protocol in place for post-exposure prophylaxis and/or treatment.
f. I will train the laboratory staff in good microbiological practices and techniques required to ensure safety for
this project, in the procedures for dealing with accidents, and in waste management procedures, prior to any
project work and at least annually thereafter.
g. I will ensure that all laboratory staff are listed with the Office of Environmental Health & Safety.
h. I will submit in writing a request for approval from the Biological Safety Committee for any significant
modifications to the study, facilities, or procedures.
i. I will supervise staff, and correct work errors and conditions that could result in breach of the NIH Guidelines
or Brown University policy.
j. I will submit to the Biosafety Officer, the Biological Safety Committee, and the Office of Recombinant DNA
Activities at NIH (if applicable), reports of any research related accident, exposure incident, release of
recombinant or synthetic nucleic acid molecules to the environment, problems pertaining to the
implementation of biological and physical containment procedures, or violations of the NIH Guidelines
Please identify either yourself or another individual who has significant and appropriate microbiological education and experience to conduct the work at
the biosafety level requested and with the biohazards identified.
Circle one:
Self
Other ____________________________________________
Name of Identified Individual
Signature _________________________________________
Electronic Signature of Identified Individual
As Principal Investigator, I accept responsibility for the safe conduct of work with this material. I will ensure that all personnel receive
training in regard to proper safety practices and protective equipment needed for this work.
Brown University Environmental Health and Safety
Created: November 2011
Reviewed: March 2013
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